Paramount Elite Preferred PPO (PPO) is a Medicare Advantage (Part C) Plan by Paramount Elite Medicare Plans.
This page features plan details for 2023 Paramount Elite Preferred PPO (PPO) H5232 – 001 – 0 available in Paramount Elite Preferred PPO (Northwestern Ohio).
Paramount Elite Preferred PPO (PPO) is offered in the following locations.
Paramount Elite Preferred PPO (PPO) offers the following coverage and cost-sharing.
| Insurer: | Paramount Elite Medicare Plans |
| Health Plan Deductible: | $500 annual deductible |
| MOOP: | $8,950 In and Out-of-network $5,300 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Paramount Elite Preferred PPO (PPO) ?
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $164.90 | $25.30 | $39.70 | $0.00 | $229.90 |
Paramount Elite Preferred PPO (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $39.70 | $31.00 | $22.30 | $13.70 | $5.00 |
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $10.00 copay | $10.00 copay | ||
| 3 (Preferred Brand) | $45.00 copay | $45.00 copay | ||
| 4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | ||
| 5 (Specialty Tier) | 33% |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $30.00 copay | $20.00 copay | ||
| 3 (Preferred Brand) | $135.00 copay | $90.00 copay | ||
| 4 (Non-Preferred Drug) | $300.00 copay | $200.00 copay | ||
| 5 (Specialty Tier) |
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $10.00 copay | $10.00 copay |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $30.00 copay | $20.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Paramount Elite Preferred PPO (PPO) also provides the following benefits.
| In-Network: No |
| Diagnostic services: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Diagnostic services: | Out-of-Network: $0 copay or 0-30% coinsurance (limits may apply) (authorization required) (referral not required) |
| Endodontics: | In-Network: 30% coinsurance (limits may apply) (authorization required) (referral not required) |
| Endodontics: | Out-of-Network: $0 copay or 0-30% coinsurance (limits may apply) (authorization required) (referral not required) |
| Extractions: | In-Network: 30% coinsurance (limits may apply) (authorization required) (referral not required) |
| Extractions: | Out-of-Network: $0 copay or 0-30% coinsurance (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | Out-of-Network: $0 copay or 0-30% coinsurance (limits may apply) (authorization required) (referral not required) |
| Periodontics: | In-Network: 30% coinsurance (limits may apply) (authorization required) (referral not required) |
| Periodontics: | Out-of-Network: $0 copay or 0-30% coinsurance (limits may apply) (authorization required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | In-Network: 30% coinsurance (limits may apply) (authorization required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Out-of-Network: $0 copay or 0-30% coinsurance (limits may apply) (authorization required) (referral not required) |
| Restorative services: | In-Network: 30% coinsurance (limits may apply) (authorization required) (referral not required) |
| Restorative services: | Out-of-Network: $0 copay or 0-30% coinsurance (limits may apply) (authorization required) (referral not required) |
| Cleaning: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Cleaning: | Out-of-Network: $0 copay or 0-30% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | Out-of-Network: $0 copay or 0-30% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | Out-of-Network: $0 copay or 0-30% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Oral exam: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Oral exam: | Out-of-Network: $0 copay or 0-30% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Diagnostic radiology services (e.g., MRI): | In-Network: $0-130 copay (authorization required) (referral not required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 10% coinsurance (authorization required) (referral not required) |
| Diagnostic tests and procedures: | In-Network: $50 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | Out-of-Network: 10% coinsurance (authorization required) (referral not required) |
| Lab services: | In-Network: $0-10 copay (authorization required) (referral not required) |
| Lab services: | Out-of-Network: 10% coinsurance (authorization required) (referral not required) |
| Outpatient x-rays: | In-Network: $50 copay (authorization required) (referral not required) |
| Outpatient x-rays: | Out-of-Network: 10% coinsurance (authorization required) (referral not required) |
| Primary: | In-Network: $0 copay |
| Primary: | Out-of-Network: $25 copay per visit |
| Specialist: | In-Network: $30 copay per visit (authorization not required) (referral not required) |
| Specialist: | Out-of-Network: $60 copay per visit (authorization not required) (referral not required) |
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $35 copay per visit (always covered) |
| Foot exams and treatment: | In-Network: $30 copay (authorization not required) (referral not required) |
| Foot exams and treatment: | Out-of-Network: $25-60 copay (authorization not required) (referral not required) |
| Routine foot care: | In-Network: $30 copay (no limits) (authorization not required) (referral not required) |
| Routine foot care: | Out-of-Network: $25-60 copay (no limits) (authorization not required) (referral not required) |
| In-Network: $295 copay | |
| Out-of-Network: $295 copay |
| $500 annual deductible |
| In-Network: No |
| Fitting/evaluation: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fitting/evaluation: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing aids: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing aids: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing exam: | In-Network: $30 copay (authorization not required) (referral not required) |
| Hearing exam: | Out-of-Network: 10% coinsurance (authorization not required) (referral not required) |
| In-Network: $295 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) | |
| Out-of-Network: 10% per day for days 1 and beyond (authorization required) (referral not required) |
| In-Network: $0-235 copay per visit (authorization required) (referral not required) | |
| Out-of-Network: 10% coinsurance per visit (authorization required) (referral not required) |
| $8,950 In and Out-of-network $5,300 In-network |
| Diabetes supplies: | In-Network: 0-20% coinsurance per item (authorization required) |
| Diabetes supplies: | Out-of-Network: 0-20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 0-20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 10-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 20% coinsurance per item (authorization required) |
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 20% coinsurance (authorization required) |
| Inpatient hospital – psychiatric: | In-Network: $250 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) |
| Inpatient hospital – psychiatric: | Out-of-Network: 10% per day for days 1 and beyond (authorization required) (referral not required) |
| Outpatient group therapy visit: | In-Network: $30 copay (authorization not required) (referral not required) |
| Outpatient group therapy visit: | Out-of-Network: $60 copay (authorization not required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $30 copay (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: $60 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit: | In-Network: $30 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit: | Out-of-Network: $60 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $30 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: $60 copay (authorization required) (referral not required) |
| Yes |
| In-Network: $0 copay (authorization not required) (referral not required) | |
| Out-of-Network: 10% coinsurance (authorization not required) (referral not required) |
| Occupational therapy visit: | In-Network: $10 copay (authorization required) (referral not required) |
| Occupational therapy visit: | Out-of-Network: $60 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | In-Network: $10 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: $60 copay (authorization required) (referral not required) |
| In-Network: $0 per day for days 1 through 20 $188 per day for days 21 through 100 (authorization required) (referral not required) | |
| Out-of-Network: 10% per day for days 1 through 100 (authorization required) (referral not required) |
| Not covered |
| Contact lenses: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Contact lenses: | Out-of-Network: $0 copay or 10% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | Out-of-Network: $0 copay or 10% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Eyeglass lenses: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass lenses: | Out-of-Network: $0 copay or 10% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Eyeglasses (frames and lenses): | Not covered (no limits) |
| Other: | Not covered (no limits) |
| Routine eye exam: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Routine eye exam: | Out-of-Network: $0 copay or 10% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | Not covered |
| Covered (authorization required) (referral required) |
| Comprehensive dental: | Monthly Premium: | $26.60 |
| Comprehensive dental: | Deductible: | $50.00 |
Ready to sign up for Paramount Elite Preferred PPO (PPO) ?
Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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