ODS. Healthcare from your head to your toes.

ODS Advantage PPORX Select (PPO) benefits

The ODS Advantage PPORX Select plan features valuable medical and prescription drug benefits designed to help you manage your health. Some of the highlights of this plan include:

Medical benefits

Annual out-of-pocket maximum of $3,400 which includes both
in- and out- of network services
Low deductible of $50
$0 copayment for your annual physical
Routine vision exam benefit once every two years
See any Medicare provider in- or out-of-network
Travel and visitor coverage for up to 12 months in the USA
Worldwide coverage for emergency medical services

Prescription drug benefits

$120 annual deductible, after which you pay the following for up to a 30 day supply:
- $5.00 copayment for Tier 1 preferred generic drugs
- $33.00 copayment for Tier 2 non-preferred generic drugs
- $40.00 copayment for Tier 3 preferred brand drugs
- 50% coinsurance for Tier 4 non-preferred brand drugs
- 30% coinsurance for Tier 5 speciality drugs
When your total drug costs reach $2,930, you pay the following:
- 86% of the plan's cost for all generic drugs and you receive a discount on brand-name drugs until your annual out-of-pocket drug costs reach the $4,700 Catastrophic coverage limit (out-of-pocket maximum)
After your annual out-of-pocket drug costs reach $4,700, you pay the greater of:

$2.60 for generic (including brand-name drugs treated as generic) and $6.50 for all other drugs
OR
5% coinsurance

The ODS Advantage PPORX Select summary of benefits is a comparison of ODS Advantage PPO, ODS Advantage PPORX Select and Original Medicare. The charts in this booklet list some important health benefits. For each benefit, you can see what our plans cover and what Original Medicare covers.

Our members receive all of the benefits that the Original Medicare plan offers. We also offer more benefits, which may change from year to year.

The ODS Advantage PPORX Select ODS Advantage PPORX Select Annual notice of changes Evidence of Coverage includes details about plan benefits, limitations, restrictions, the appeal and grievance process and other important information. You may also call ODS Advantage member services and ask for the "evidence of coverage" or more information about plan benefits.