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Personal Choice 65 Saver Rx (PPO) - H3909-016-000
$0.00
Monthly Premium
Personal Choice 65 Saver Rx (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Independence Blue Cross
Plan ID: H3909-016-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Pennsylvania 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 Pennsylvania 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 | $0.00 |
| Out-of-pocket maximum | $8,300.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $8,000.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 40% |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 40% |
| Inpatient hospital care | In-Network: Acute Hospital Services: $375.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Maximum out of Pocket $1875.00 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $15.00 to $55.00 #4b, Urgently Needed Services: $15 copayment applies to urgently needed services received from a retail clinic. $55 copayment applies to urgently needed services received from an urgent care center. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $100.00 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 |
| Ambulance transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $260.00 Copayment for Medicare Covered Ambulance Services - Air $260.00 |
Health Care Services and Medical Supplies
Personal Choice 65 Saver Rx (PPO) covers a range of additional benefits. Learn more about Personal Choice 65 Saver Rx (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: Coinsurance for Medicare Covered Chiropractic Services 40% Chiropractic Services: Coinsurance for Non-Medicare Covered Chiropractic Services 40% |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Coinsurance for Medicare-covered Diabetic Supplies 0% to 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) |
| Durable medical equipment (DME) | Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 40% |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% Coinsurance for Medicare Covered Lab Services 40% Coinsurance for Medicare Covered Diagnostic Radiological Services 40% Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Coinsurance for Medicare Covered Outpatient X-Ray Services 40% |
| Home health care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 40% |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $375.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Maximum out of Pocket $1875.00 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | Out-of-Network: Outpatient Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 20% Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Coinsurance for Medicare Covered Observation Services 20% Ambulatory Surgical Center Services: Coinsurance for Ambulatory Surgical Center Services 20% Prior Authorization Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $30.00 Copayment for Medicare-covered Group Sessions $20.00 |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $30.00 every three months |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $25.00 Copayment for Routine Foot Care $25.00
|
| Skilled Nursing Facility (SNF) care | Out-of-Network: Coinsurance for Skilled Nursing Facility Services per Stay 40% |
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 $50.00 Coinsurance for Restorative Services 20% Coinsurance for Endodontics 20%
Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 40%
|
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $50.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00
|
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $50.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00
|
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 | Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 40% |
When reviewing Pennsylvania 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 Pennsylvania 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 |
Pennsylvania Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.