2022 Personal Choice 65 Prime Rx (PPO)

Personal Choice 65 Prime Rx (PPO) H3909-014 is a 2022 Medicare Advantage Plan or Part-C by Independence Blue Cross available to residents in Pennsylvania. This plan includes additional prescription drug (Part-D) coverage. The Personal Choice 65 Prime Rx (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $7,550 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $7,550 out-of-pocket. This can be a extremely nice safety net.

Personal Choice 65 Prime Rx (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 Prime Rx (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.

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2022 Independence Blue Cross Medicare Advantage Plan Costs

Personal Choice 65 Prime Rx (PPO) Part-C Premium

Independence Blue Cross 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.

H3909-014 Part-D Deductible and Premium

Personal Choice 65 Prime Rx (PPO) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This Independence Blue Cross 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 Independence Blue Cross 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.

Independence Blue Cross 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 Independence Blue Cross plan does not offer additional coverage through the gap.

H3909-014 Formulary or Drug Coverage

Personal Choice 65 Prime Rx (PPO) 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 Personal Choice 65 Prime Rx (PPO) H3909-014 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$9
Tier 2	$10	$20
Tier 3	$47	$47
Tier 4	$100	$100
Tier 5	33%	33%

*Initial Coverage Phase and 30 day supply

2021 Personal Choice 65 Prime Rx (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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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

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	40% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$0-275 copay
Diagnostic tests and procedures	40% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0 copay
Lab services	$0 copay
Lab services	40% coinsurance (Out-of-Network)
Outpatient x-rays	$45 copay
Outpatient x-rays	40% coinsurance (Out-of-Network)

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Doctor Visits

Primary	40% coinsurance per visit (Out-of-Network)
Primary	$5 copay per visit
Specialist	40% coinsurance per visit (Out-of-Network)
Specialist	$40 copay per visit

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$10-40 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$25 copay
Foot exams and treatment	40% coinsurance (Out-of-Network)
Routine foot care	40% coinsurance (Out-of-Network)
Routine foot care	$25 copay

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Ground Ambulance

$300 copay
$300 copay (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	$10 copay (Out-of-Network)
Hearing aids	$699-999 copay (Out-of-Network)
Hearing aids	$699-999 copay
Hearing exam	$40 copay
Hearing exam	40% coinsurance (Out-of-Network)

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Inpatient Hospital Coverage

40% per stay (Out-of-Network)
$250 per day for days 1 through 7 $0 per day for days 8 through 90

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Medical Equipment/Supplies

Diabetes supplies	40% 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)	40% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	40% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	40% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance
Other Part B drugs	40% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	40% per stay (Out-of-Network)
Inpatient hospital - psychiatric	$250 per day for days 1 through 7 $0 per day for days 8 through 90
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit	40% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	40% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit	40% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit with a psychiatrist	40% coinsurance (Out-of-Network)

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MOOP

$11,300 In and Out-of-network $7,550 In-network

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Option

Yes, contact plan for further details

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

$375 copay per visit
40% coinsurance per visit (Out-of-Network)

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Preventive Care

$0 copay
40% coinsurance (Out-of-Network)

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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

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Rehabilitation Services

Occupational therapy visit	$30 copay
Occupational therapy visit	40% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	40% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$30 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $184 per day for days 21 through 100
40% per stay (Out-of-Network)

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Transportation

Not covered

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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

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Personal Choice 65 Prime Rx (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 Prime Rx (PPO) Plans Performance

Health Plan Customer Service Rating for Personal Choice 65 Prime Rx (PPO)

Personal Choice 65 Prime Rx (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 Prime Rx (PPO)

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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.