2022 Vermont Blue Advantage Unity HMO (HMO)

Vermont Blue Advantage Unity HMO (HMO) H9489-001 is a 2022 Medicare Advantage Plan or Part-C by Vermont Blue Advantage available to residents in Vermont. This plan includes additional prescription drug (Part-D) coverage. The Vermont Blue Advantage Unity HMO (HMO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $6,600 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,600 out-of-pocket. This can be a extremely nice safety net.

Vermont Blue Advantage Unity HMO (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered.

Vermont Blue Advantage works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Vermont Blue Advantage Unity HMO (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Vermont Blue Advantage and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Vermont Blue Advantage except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Vermont Blue Advantage Medicare Advantage Plan Costs

Vermont Blue Advantage Unity HMO (HMO)
Plan ID:
Provider:Vermont Blue Advantage
Type: Local HMO
Monthly Premium C+D: $0
Part C Premium:$0.00
MOOP: $6,600
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$200.00
Tiers with No Deductible:1
Gap Coverage:No
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H9489-001
New Plan: 2023 H9489-001

Vermont Blue Advantage Unity HMO (HMO) Part-C Premium

Vermont Blue Advantage charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H9489-001 Part-D Deductible and Premium

Vermont Blue Advantage Unity HMO (HMO) has a monthly drug premium of $0.00 and a $200.00 drug deductible. This Vermont Blue Advantage plan offers a $0.00 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 $0.00 this Premium covers any enhanced plan benefits offered by Vermont Blue Advantage above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Vermont Blue Advantage Gap Coverage

In 2022 once you and your plan provider have spent $4430 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 additional coverage. This Vermont Blue Advantage plan does not offer additional coverage through the gap.

H9489-001 Formulary or Drug Coverage

Vermont Blue Advantage Unity HMO (HMO) 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. You can see complete 2022 Vermont Blue Advantage Unity HMO (HMO) H9489-001 Formulary here.

Drug Tier Copay
Tier 1 $0 $10
Tier 2 $10 $20
Tier 3 $45 $47
Tier 4 $100 $100
Tier 5 29% 29%
*Initial Coverage Phase and 30 day supply

2021 Vermont Blue Advantage Unity HMO (HMO) Summary of Benefits

*This will be updated with 2022 data when available.

Additional Benefits


Comprehensive Dental

Diagnostic services 25% coinsurance
Endodontics 25% coinsurance
Extractions 25% coinsurance
Non-routine services Not covered
Periodontics 25% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services 25% coinsurance
Restorative services 25% coinsurance



Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI) $10-275 copay
Diagnostic tests and procedures $20-275 copay
Lab services $10-30 copay
Outpatient x-rays $10-275 copay

Doctor Visits

Primary $0 copay
Specialist $35 copay per visit

Emergency care/Urgent Care

Emergency $90 copay per visit (always covered)
Urgent care $45 copay per visit (always covered)

Foot Care (podiatry services)

Foot exams and treatment $45 copay
Routine foot care Not covered

Ground Ambulance

$250 copay


Fitting/evaluation $0 copay
Hearing aids $0 copay
Hearing exam $10-40 copay

Inpatient Hospital Coverage

$365 per day for days 1 through 5
$0 per day for days 6 through 90

Medical Equipment/Supplies

Diabetes supplies 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) 20% coinsurance per item

Medicare Part B Drugs

Chemotherapy 0-20% coinsurance
Other Part B drugs 0-20% coinsurance

Mental Health Services

Inpatient hospital - psychiatric $365 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient group therapy visit $35 copay
Outpatient group therapy visit with a psychiatrist $35 copay
Outpatient individual therapy visit $35 copay
Outpatient individual therapy visit with a psychiatrist $35 copay


$6,700 In-network


Yes, contact plan for further details

Optional supplemental benefits


Outpatient Hospital Coverage

$275 copay per visit

Preventive Care

$0 copay

Preventive Dental

Cleaning $0 copay
Dental x-ray(s) $0 copay
Fluoride treatment $0 copay
Oral exam $0 copay

Rehabilitation Services

Occupational therapy visit $35 copay
Physical therapy and speech and language therapy visit $35 copay

Skilled Nursing Facility

$0 per day for days 1 through 20
$175 per day for days 21 through 100


Not covered


Contact lenses $0 copay
Eyeglass frames $0 copay
Eyeglass lenses $0 copay
Eyeglasses (frames and lenses) $0 copay
Other Not covered
Routine eye exam $0 copay
Upgrades Not covered

Wellness Programs (e.g. fitness nursing hotline)


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Coverage Area for Vermont Blue Advantage Unity HMO (HMO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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HealthCompare Insurance Services, HealthPlanOne, LLC, ClearMatch Medicare and Medicare Solutions does not offer every plan available in your area. Currently HealthCompare Insurance Services represent 18 organizations, which offers 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. HealthCompare Insurance Services, HealthPlanOne, LLC, ClearMatch Medicare and Medicare Solutions represents Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan’s contract renewal.


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