2022 Personal Choice 65 Medical Only (PPO)

Personal Choice 65 Medical Only (PPO) H3909-007 is a 2022 Medicare Advantage Plan or Part-C by Independence Blue Cross available to residents in Pennsylvania. This plan does not provide additional prescription drug (Part-D) coverage. The Personal Choice 65 Medical Only (PPO) has a monthly premium of $179.00 and has an in-network maximum out-of-pocket limit of $5,000 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,000 out-of-pocket. This can be a extremely nice safety net.

Personal Choice 65 Medical Only (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.

Independence Blue Cross works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Personal Choice 65 Medical Only (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Independence Blue Cross 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 Independence Blue Cross except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

2022 Independence Blue Cross Medicare Advantage Plan Costs

2021 Personal Choice 65 Medical Only (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

---

Additional Benefits

No

---

Comprehensive Dental

Diagnostic services	Not covered
Endodontics	80% coinsurance (Out-of-Network)
Endodontics	20% coinsurance
Extractions	80% coinsurance (Out-of-Network)
Extractions	20% coinsurance
Non-routine services	Not covered
Periodontics	20% coinsurance
Periodontics	80% coinsurance (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	40% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services	80% coinsurance (Out-of-Network)
Restorative services	80% coinsurance (Out-of-Network)
Restorative services	20% coinsurance

---

Deductible

$0

---

Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	30% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$0-175 copay
Diagnostic tests and procedures	30% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0 copay
Lab services	$0 copay
Lab services	30% coinsurance (Out-of-Network)
Outpatient x-rays	$40 copay
Outpatient x-rays	30% coinsurance (Out-of-Network)

---

Doctor Visits

Primary	30% coinsurance per visit (Out-of-Network)
Primary	$5 copay per visit
Specialist	30% coinsurance per visit (Out-of-Network)
Specialist	$35 copay per visit

---

Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$5-40 copay per visit (always covered)

---

Foot Care (podiatry services)

Foot exams and treatment	$20 copay
Foot exams and treatment	30% coinsurance (Out-of-Network)
Routine foot care	30% coinsurance (Out-of-Network)
Routine foot care	$20 copay

---

Ground Ambulance

$175 copay
$175 copay (Out-of-Network)

---

Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	$10 copay (Out-of-Network)
Hearing aids	$499-799 copay (Out-of-Network)
Hearing aids	$499-799 copay
Hearing exam	$35 copay
Hearing exam	30% coinsurance (Out-of-Network)

---

Inpatient Hospital Coverage

30% per stay (Out-of-Network)
$240 per day for days 1 through 6 $0 per day for days 7 through 90

---

Medical Equipment/Supplies

Diabetes supplies	30% coinsurance per item (Out-of-Network)
Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	30% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	30% coinsurance per item (Out-of-Network)

---

Medicare Part B Drugs

Chemotherapy	30% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance
Other Part B drugs	30% coinsurance (Out-of-Network)

---

Mental Health Services

Inpatient hospital - psychiatric	30% per stay (Out-of-Network)
Inpatient hospital - psychiatric	$240 per day for days 1 through 6 $0 per day for days 7 through 90
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit	30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit	30% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit with a psychiatrist	30% coinsurance (Out-of-Network)

---

MOOP

$10,000 In and Out-of-network $5,000 In-network

---

Option

Yes, contact plan for further details

---

Optional supplemental benefits

No

---

Outpatient Hospital Coverage

$300 copay per visit
30% coinsurance per visit (Out-of-Network)

---

Preventive Care

$0 copay
30% coinsurance (Out-of-Network)

---

Preventive Dental

Cleaning	80% coinsurance (Out-of-Network)
Cleaning	$0 copay
Dental x-ray(s)	80% coinsurance (Out-of-Network)
Dental x-ray(s)	$0 copay
Fluoride treatment	Not covered
Oral exam	80% coinsurance (Out-of-Network)
Oral exam	$0 copay

---

Rehabilitation Services

Occupational therapy visit	$20 copay
Occupational therapy visit	30% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	30% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$20 copay

---

Skilled Nursing Facility

$0 per day for days 1 through 20 $184 per day for days 21 through 100
30% per stay (Out-of-Network)

---

Transportation

Not covered

---

Vision

Contact lenses	$0 copay
Contact lenses	80% coinsurance (Out-of-Network)
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	$0 copay
Eyeglasses (frames and lenses)	80% coinsurance (Out-of-Network)
Other	Not covered
Routine eye exam	80% coinsurance (Out-of-Network)
Routine eye exam	$10 copay
Upgrades	Not covered

---

Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Personal Choice 65 Medical Only (PPO) H3909

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Personal Choice 65 Medical Only (PPO) Plans Performance

Health Plan Customer Service Rating for Personal Choice 65 Medical Only (PPO)

Personal Choice 65 Medical Only (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Personal Choice 65 Medical Only (PPO)

(Click county to compare all available Advantage plans)

Go to top

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.