Ascension Complete St Vincent Access (PPO) H1774-002 is a 2023 Medicare Advantage Plan or Part-C by Ascension Complete available to residents in Indiana. This plan includes extra prescription drug (Part-D) coverage. Ascension Complete Ascension Complete St Vincent Access (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $2,900 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $2,900 out-of-pocket. This can be an extremely nice safety net.

Ascension Complete works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Ascension Complete St Vincent Access (PPO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Ascension Complete and not Original Medicare. With 2023 Medicare Advantage Plan you are always covered for urgently needed and emergency care. Plus, you receive all the benefits of Original Medicare from Ascension Complete except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in Indiana.

2023 Ascension Complete Medicare Advantage Plan Overview

What type of plan is Ascension Complete St Vincent Access (PPO)

Ascension Complete St Vincent Access (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network, but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

How much does Ascension Complete St Vincent Access (PPO) cost?

Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Ascension Complete charges a $0 consolidated premium. The Part C premium is $0 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Ascension Complete St Vincent Access (PPO) has a monthly drug premium of $0 and a $0 drug deductible. This Ascension Complete plan offers a $0 Part-D Basic Premium that is Not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0. This Premium covers any enhanced plan benefits offered by Ascension Complete above and beyond the standard PDP benefits. This can include extra coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $0. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Ascension Complete Gap Coverage

In 2023 once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers extra coverage. This Ascension Complete plan does not offer extra coverage through the gap.

MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Ascension Complete St Vincent Access (PPO) by Ascension Complete MOOP is $2,900. Once you spend $2,900 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.

Formulary and Drug Coverage

Ascension Complete St Vincent Access (PPO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$5
Tier 2	$5	$10
Tier 3	$37	$47
Tier 4	$90	$100
Tier 5	33%	33%
Tier 6	$0	$0

The complete Ascension Complete St Vincent Access (PPO) Formulary.
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what Ascension Complete St Vincent Access (PPO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Ascension Complete helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)	Covered

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Contact lenses

Out-of-Network Vision	40% coinsurance
In-Network Vision	$0 copay

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Eyeglass frames

Out-of-Network Vision	40% coinsurance
In-Network Vision	$0 copay

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Eyeglass lenses

In-Network Vision	$0 copay
Out-of-Network Vision	40% coinsurance

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Eyeglasses (frames and lenses)

In-Network Vision	$0 copay
Out-of-Network Vision	40% coinsurance

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Other

Vision	Not covered

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Routine eye exam

Out-of-Network Vision	40% coinsurance
In-Network Vision	$0 copay

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Upgrades

In-Network Vision	$0 copay
Out-of-Network Vision	40% coinsurance

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Transportation	Not covered
Out-of-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 100
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 40 $0 per day for days 41 through 100

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Occupational therapy visit

In-Network Rehabilitation services	20% coinsurance
Out-of-Network Rehabilitation services	20% coinsurance

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Physical therapy and speech and language therapy visit

Out-of-Network Rehabilitation services	20% coinsurance
In-Network Rehabilitation services	20% coinsurance

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Cleaning

Out-of-Network Preventive dental	70% coinsurance
In-Network Preventive dental	$0 copay

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Dental x-ray(s)

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	70% coinsurance

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Fluoride treatment

Out-of-Network Preventive dental	70% coinsurance
In-Network Preventive dental	$0 copay

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Oral exam

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	70% coinsurance

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In-Network Preventive care	$0 copay
Out-of-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	20% coinsurance per visit
Out-of-Network Outpatient hospital coverage	20% coinsurance per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	No

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Inpatient hospital - psychiatric

Out-of-Network Mental health services	$575 per day for days 1 through 4 $0 per day for days 5 through 90
In-Network Mental health services	$575 per day for days 1 through 4 $0 per day for days 5 through 90

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Outpatient group therapy visit

Out-of-Network Mental health services	20% coinsurance
In-Network Mental health services	20% coinsurance

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Outpatient group therapy visit with a psychiatrist

Out-of-Network Mental health services	20% coinsurance
In-Network Mental health services	20% coinsurance

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Outpatient individual therapy visit

Out-of-Network Mental health services	20% coinsurance
In-Network Mental health services	20% coinsurance

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Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	20% coinsurance
Out-of-Network Mental health services	20% coinsurance

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Chemotherapy

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	20% coinsurance

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Other Part B drugs

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	20% coinsurance

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Diabetes supplies

In-Network Medical equipment/supplies	$0 copay per item
Out-of-Network Medical equipment/supplies	$0-125 copay or 20% coinsurance per item

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Durable medical equipment (e.g., wheelchairs, oxygen)

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	20% coinsurance per item

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Prosthetics (e.g., braces, artificial limbs)

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	20% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$5,450 In and Out-of-network $2,900 In-network
Out-of-Network Inpatient hospital coverage	$440 per day for days 1 through 4 $0 per day for days 5 and beyond
In-Network Inpatient hospital coverage	$440 per day for days 1 through 4 $0 per day for days 5 through 90 $0 per day for days 91 and beyond

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Fitting/evaluation

In-Network Hearing	$0 copay
Out-of-Network Hearing	40% coinsurance

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Hearing aids

In-Network Hearing	$0 copay
Out-of-Network Hearing	40% coinsurance

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Hearing exam

Out-of-Network Hearing	20% coinsurance
In-Network Hearing	20% coinsurance

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Health plan deductible	$0
In-Network Ground ambulance	20% coinsurance
Out-of-Network Ground ambulance	20% coinsurance

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Foot exams and treatment

In-Network Foot care (podiatry services)	20% coinsurance
Out-of-Network Foot care (podiatry services)	20% coinsurance

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Routine foot care

In-Network Foot care (podiatry services)	20% coinsurance
Out-of-Network Foot care (podiatry services)	20% coinsurance

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Emergency

Emergency care/Urgent care	$125 copay per visit (always covered)

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Urgent care

Emergency care/Urgent care	$40 copay per visit (always covered)

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Primary

Out-of-Network Doctor visits	$25 copay per visit
In-Network Doctor visits	$0 copay

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Specialist

Out-of-Network Doctor visits	20% coinsurance per visit
In-Network Doctor visits	20% coinsurance per visit

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Diagnostic radiology services (e.g., MRI)

Out-of-Network Diagnostic procedures/lab services/imaging	$0-125 copay or 20% coinsurance
In-Network Diagnostic procedures/lab services/imaging	$0 copay or 20% coinsurance

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Diagnostic tests and procedures

In-Network Diagnostic procedures/lab services/imaging	$0 copay or 20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging	$0-125 copay or 20% coinsurance

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Lab services

In-Network Diagnostic procedures/lab services/imaging	$0 copay or 20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging	$0-125 copay or 20% coinsurance

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Outpatient x-rays

In-Network Diagnostic procedures/lab services/imaging	20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging	20% coinsurance

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Diagnostic services

Out-of-Network Comprehensive dental	70% coinsurance
In-Network Comprehensive dental	40% coinsurance

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Endodontics

In-Network Comprehensive dental	40% coinsurance
Out-of-Network Comprehensive dental	70% coinsurance

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Extractions

In-Network Comprehensive dental	40% coinsurance
Out-of-Network Comprehensive dental	70% coinsurance

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Non-routine services

In-Network Comprehensive dental	40% coinsurance
Out-of-Network Comprehensive dental	70% coinsurance

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Periodontics

In-Network Comprehensive dental	40% coinsurance
Out-of-Network Comprehensive dental	70% coinsurance

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Prosthodontics, other oral/maxillofacial surgery, other services

In-Network Comprehensive dental	40% coinsurance
Out-of-Network Comprehensive dental	70% coinsurance

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Restorative services

Out-of-Network Comprehensive dental	70% coinsurance
In-Network Comprehensive dental	40% coinsurance

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In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	No

Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Ascension Complete St Vincent Access (PPO) requires you to live in that plan’s service area. The service area is listed below:

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Source:CMS. Data as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.