Saint Alphonsus Health Plan No Premium Choice (PPO)
Saint Alphonsus Health Plan No Premium Choice (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Trinity Health
Plan ID: H3828-001-000
Idaho Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Idaho Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $150.00 |
| Out-of-pocket maximum | $6,100.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $7,400.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $30.00 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $35.00 |
| Inpatient hospital care | Out-of-Network: Coinsurance for Acute Hospital Services per Stay 30% |
| Urgent care | Urgent Care: Copayment for Urgent Care $35.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $90.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $90.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 48 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $90.00 Copayment for Worldwide Emergency Transportation $250.00 to $300.00 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $250.00 Air Ambulance: Copayment for Air Ambulance Services $300.00 Prior Authorization is required for Non Urgent Fixed Wing, Rotary and Mileage. Please see Evidence of Coverage for Prior Authorization rules |
Health Care Services and Medical Supplies
Saint Alphonsus Health Plan No Premium Choice (PPO) covers a range of additional benefits. Learn more about Saint Alphonsus Health Plan No Premium Choice (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $60.00 |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0.00 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Prior Authorization Required for Diabetic Supplies and Services |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $30.00 Copayment for Medicare-covered Lab Services $5.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $150.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $20.00 |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 |
| Mental health inpatient care | Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 30% |
| Mental health outpatient care | Out-of-Network: Outpatient Mental Health Services: Copayment for Medicare Covered Individual Sessions $60.00 Copayment for Medicare Covered Group Sessions $60.00 |
| Outpatient services/surgery | Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 30% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30% |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual or Group Sessions 30% |
| Over-the-counter items | Out-of-Network: Over-The-Counter (OTC) Items: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $100.00 |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $35.00 |
| Skilled Nursing Facility (SNF) care | Out-of-Network: Coinsurance for Skilled Nursing Facility Services per Stay 30% |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $35.00 Copayment for Diagnostic Services $0.00 Coinsurance for Restorative Services 50% Coinsurance for Endodontics 70% Coinsurance for Periodontics 70% Coinsurance for Extractions 50% Maximum Plan Benefit of $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Vision benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $35.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Maximum Plan Allowance of $125.00 every year for all Non-Medicare covered eyewear for in and out of network services combined |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing benefits | Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $60.00 Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $60.00 to $899.00 Copayment for Non-Medicare Covered Hearing Aids $60.00 to $899.00 |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The Saint Alphonsus Health Plan No Premium Choice (PPO) offers prescription drug coverage, with an annual drug deductible of $150.00 (excludes Tiers 1 and 2)
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual drug deductible | $150.00 (excludes Tiers 1 and 2) |
| Tier 1 | |
| Tier 2 | |
| Annual drug deductible | $150.00 (excludes Tiers 1 and 2) |
| Tier 1 | |
| Tier 2 | |
| Annual drug deductible | $150.00 (excludes Tiers 1 and 2) |
| Tier 1 | |
| Tier 2 | |
When reviewing Idaho Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Idaho that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents | |
Idaho Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
