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Blue Medicare Advantage PPO (PPO) - H5900-003-000

4 out of 5 stars* for plan year 2024

$19.00

Monthly Premium

Blue Medicare Advantage PPO (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aware Integrated, Inc.

Plan ID: H5900-003-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$19.00

Monthly Premium

South Dakota 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 South Dakota 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

CoverageDetails
Monthly plan premium$19.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$4,200.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40.00
Inpatient hospital care
Out-of-Network:
$365.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Urgent care
Urgent Care:
Copayment for Urgent Care $45.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $120.00
Maximum Plan Benefit of $50000.00
Emergency room visit
Emergency Care:
Copayment for Emergency Care $120.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $120.00
Copayment for Worldwide Emergency Transportation $120.00
Maximum Plan Benefit of $50000.00
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $325.00
Copayment for Medicare Covered Ambulance Services - Air $325.00

Health Care Services and Medical Supplies

Blue Medicare Advantage PPO (PPO) covers a range of additional benefits. Learn more about Blue Medicare Advantage PPO (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $20.00
Copayment for Routine Care $30.00
  • Maximum 14 Routine Care every year
Copayment for Chiropractic X-rays $0.00
  • Maximum 1 Set every year
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare-covered Diabetic Supplies 20.00%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20.00%
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 0.00% to 20.00%
Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-rays
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00 to $100.00
Copayment for Medicare Covered Lab Services $5.00
Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $100.00
Coinsurance for Medicare Covered Therapeutic Radiological Services 20.00%
Copayment for Medicare Covered Outpatient X-Ray Services $20.00
Home health care
Out-of-Network:

Home Health Services:
Copayment for Medicare Covered Home Health $0.00
Mental health inpatient care
Out-of-Network:
$365.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Mental health outpatient care
Out-of-Network:

Outpatient Mental Health Services:
Copayment for Medicare Covered Individual Sessions $40.00
Copayment for Medicare Covered Group Sessions $40.00
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $40.00 to $350.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $200.00
Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $85.00 every three months
Podiatry services
Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $45.00
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 55
$0.00 per day for days 56 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental care
Out-of-Network:

Medicare Covered Dental Services:
Copayment for Medicare Covered Comprehensive Dental $40.00
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $15.00
Coinsurance for Non-Medicare Covered Comprehensive Dental 0.00% to 50.00%

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision care
Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $0.00 to $40.00
Non-Medicare Covered Vision Services:
Coinsurance for Non-Medicare Covered Eye Exams 50.00%
Coinsurance for Non-Medicare Covered Eyewear 50.00%

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing care
Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $0.00 to $40.00
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $0.00
Copayment for Non-Medicare Covered Hearing Aids $0.00

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.

CoverageDetails
Preventive services and health/wellness education programs
Out-of-Network:

Medicare-covered Zero Dollar Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0.00

When reviewing South Dakota 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 South Dakota 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

South Dakota Counties Served

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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