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2023 Blue Medicare Advantage PPO (PPO)

Blue Medicare Advantage PPO (PPO) H5900-003 is a 2023 Medicare Advantage Plan or Part-C by Wellmark Advantage Health Plan available to residents in South Dakota. This plan includes extra prescription drug (Part-D) coverage. Wellmark Advantage Health Plan Blue Medicare Advantage PPO (PPO) has a monthly premium of $19.00 and has an in-network maximum out-of-pocket limit of $4,200 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $4,200 out-of-pocket. This can be an extremely nice safety net.

Wellmark Advantage Health Plan works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Blue Medicare Advantage PPO (PPO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Wellmark Advantage Health Plan and not Original Medicare. With 2023 Medicare Advantage Plan you are always covered for urgently needed and emergency care. Plus, you receive all the benefits of Original Medicare from Wellmark Advantage Health Plan except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in South Dakota.



2023 Wellmark Advantage Health Plan Medicare Advantage Plan Overview

Name:Blue Medicare Advantage PPO (PPO)
Plan ID:H5900 003 0
Provider:Wellmark Advantage Health Plan
Year:2023
Type:Local PPO
Combined Premium (C+D):$19.00/mo
Part C Premium:$0/mo
MOOP:$4,200/yr
Part D (Drug) Premium:$19.00/mo
Part D Supplemental Premium$0/mo
Total Part D Premium:$19.00/mo
Drug Deductible:$0/yr
Tiers with No Deductible:0
Gap Coverage:No
Benchmark:Not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H5900-004




What type of plan is Blue Medicare Advantage PPO (PPO)

Blue Medicare Advantage PPO (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.



How much does Blue Medicare Advantage PPO (PPO) cost?


Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Wellmark Advantage Health Plan charges a $19.00 consolidated premium. The Part C premium is $0 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.


Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Blue Medicare Advantage PPO (PPO) has a monthly drug premium of $19.00 and a $0 drug deductible. This Wellmark Advantage Health Plan plan offers a $19.00 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. This Premium covers any enhanced plan benefits offered by Wellmark Advantage Health Plan above and beyond the standard PDP benefits. This can include extra coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $19.00. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.


Wellmark Advantage Health Plan Gap Coverage

In 2023 once you and your plan provider have spent $4660 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 extra coverage. This Wellmark Advantage Health Plan plan does not offer extra coverage through the gap.


Extra Help Premium Assistance

The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The Blue Medicare Advantage PPO (PPO) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $4.70 for 75% low-income subsidy $9.50 for 50% and $14.20 for 25%.


Full Assistance Premium:$0
75% Assistance Premium:$4.70
50% Assistance Premium:$9.50
25% Assistance Premium:$14.20


MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Blue Medicare Advantage PPO (PPO) by Wellmark Advantage Health Plan MOOP is $4,200. Once you spend $4,200 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.



Formulary and Drug Coverage

Blue Medicare Advantage PPO (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.

Drug Tier Copay
Preferred
Pharmacy		 Copay
Nonpreferred
Pharmacy
Tier 1 $0 $12
Tier 2 $10 $18
Tier 3 $47 $47
Tier 4 $100 $100
Tier 5 33% 33%

The complete Blue Medicare Advantage PPO (PPO) Formulary.
*Initial Coverage Phase and 30 day supply





2023 Summary of Benefits


The benefit information provided is a summary of what Blue Medicare Advantage PPO (PPO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Wellmark Advantage Health Plan helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)Covered


Contact lenses


In-Network Vision$0 copay
Out-of-Network Vision0-50% coinsurance


Eyeglass frames


Out-of-Network Vision0-50% coinsurance
In-Network Vision$0 copay


Eyeglass lenses


In-Network Vision$0 copay
Out-of-Network Vision0-50% coinsurance


Eyeglasses (frames and lenses)


In-Network Vision$0 copay
Out-of-Network Vision0-50% coinsurance


Other


VisionNot covered


Routine eye exam


In-Network Vision$0 copay
Out-of-Network Vision0-50% coinsurance


Upgrades


VisionNot covered



TransportationNot covered
Out-of-Network Skilled Nursing Facility$0 per day for days 1 through 20
$187 per day for days 21 through 55
$0 per day for days 56 through 100
In-Network Skilled Nursing Facility$0 per day for days 1 through 20
$187 per day for days 21 through 55
$0 per day for days 56 through 100


Occupational therapy visit


Out-of-Network Rehabilitation services$40 copay
In-Network Rehabilitation services$40 copay


Physical therapy and speech and language therapy visit


In-Network Rehabilitation services$40 copay
Out-of-Network Rehabilitation services$40 copay


Cleaning


Preventive dentalCovered under office visit


Dental x-ray(s)


Preventive dentalCovered under office visit


Fluoride treatment


Preventive dentalNot covered


Office visit


Out-of-Network Preventive dental$20 copay
In-Network Preventive dental$20.00


Oral exam


Preventive dentalCovered under office visit



In-Network Preventive care$0 copay
Out-of-Network Preventive care$0 copay
Out-of-Network Outpatient hospital coverage$0-325 copay per visit
In-Network Outpatient hospital coverage$40-325 copay per visit
In-Network Other health plan deductibles?No
Optional supplemental benefitsNo


Inpatient hospital - psychiatric


In-Network Mental health services$365 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-Network Mental health services$365 per day for days 1 through 5
$0 per day for days 6 through 90


Outpatient group therapy visit


Out-of-Network Mental health services$40 copay
In-Network Mental health services$40 copay


Outpatient group therapy visit with a psychiatrist


Out-of-Network Mental health services$40 copay
In-Network Mental health services$40 copay


Outpatient individual therapy visit


In-Network Mental health services$40 copay
Out-of-Network Mental health services$40 copay


Outpatient individual therapy visit with a psychiatrist


In-Network Mental health services$40 copay
Out-of-Network Mental health services$40 copay


Chemotherapy


Out-of-Network Medicare Part B drugs20-35% coinsurance
In-Network Medicare Part B drugs20% coinsurance


Other Part B drugs


Out-of-Network Medicare Part B drugs20-35% coinsurance
In-Network Medicare Part B drugs20% coinsurance


Diabetes supplies


Out-of-Network Medical equipment/supplies0-20% coinsurance per item
In-Network Medical equipment/supplies0-20% coinsurance per item


Durable medical equipment (e.g., wheelchairs, oxygen)


In-Network Medical equipment/supplies0-20% coinsurance per item
Out-of-Network Medical equipment/supplies0-20% coinsurance per item


Prosthetics (e.g., braces, artificial limbs)


Out-of-Network Medical equipment/supplies0-20% coinsurance per item
In-Network Medical equipment/supplies20% coinsurance per item



Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$4,200 In and Out-of-network
$4,200 In-network
Out-of-Network Inpatient hospital coverage$365 per day for days 1 through 5
$0 per day for days 6 through 90
In-Network Inpatient hospital coverage$365 per day for days 1 through 5
$0 per day for days 6 through 90


Fitting/evaluation


In-Network Hearing$0 copay
Out-of-Network Hearing$0 copay


Hearing aids


In-Network Hearing$0 copay
Out-of-Network Hearing$0 copay


Hearing exam


In-Network Hearing$0-40 copay
Out-of-Network Hearing$0-40 copay



Health plan deductible$0
Out-of-Network Ground ambulance$250 copay
In-Network Ground ambulance$250 copay


Foot exams and treatment


In-Network Foot care (podiatry services)$45 copay
Out-of-Network Foot care (podiatry services)$45-55 copay


Routine foot care


Foot care (podiatry services)Not covered


Emergency


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


Urgent care


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


Primary


Out-of-Network Doctor visits$0 copay
In-Network Doctor visits$0 copay


Specialist


Out-of-Network Doctor visits$40 copay per visit
In-Network Doctor visits$40 copay per visit


Diagnostic radiology services (e.g., MRI)


In-Network Diagnostic procedures/lab services/imaging$0-100 copay
Out-of-Network Diagnostic procedures/lab services/imaging$0-100 copay


Diagnostic tests and procedures


In-Network Diagnostic procedures/lab services/imaging$0-100 copay
Out-of-Network Diagnostic procedures/lab services/imaging$0-100 copay


Lab services


In-Network Diagnostic procedures/lab services/imaging$5 copay
Out-of-Network Diagnostic procedures/lab services/imaging$5 copay


Outpatient x-rays


Out-of-Network Diagnostic procedures/lab services/imaging$20 copay
In-Network Diagnostic procedures/lab services/imaging$20 copay


Diagnostic services


Comprehensive dentalNot covered


Endodontics


Comprehensive dentalNot covered


Extractions


Out-of-Network Comprehensive dental0-50% coinsurance
In-Network Comprehensive dental50% coinsurance


Non-routine services


Comprehensive dentalNot covered


Periodontics


In-Network Comprehensive dental0-50% coinsurance
Out-of-Network Comprehensive dental0-50% coinsurance


Prosthodontics, other oral/maxillofacial surgery, other services


Out-of-Network Comprehensive dental0-50% coinsurance
In-Network Comprehensive dental0-50% coinsurance


Restorative services


In-Network Comprehensive dental50% coinsurance
Out-of-Network Comprehensive dental0-50% coinsurance



In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?Yes, contact plan for further details




Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Blue Medicare Advantage PPO (PPO) requires you to live in that plan’s service area. The service area is listed below:

State: South Dakota Medicare
County:Aurora County MA Plans

Bon Homme County MA Plans

Brookings County MA Plans

Butte County MA Plans

Charles Mix County MA Plans

Clark County MA Plans

Clay County MA Plans

Custer County MA Plans

Davison County MA Plans

Day County MA Plans

Deuel County MA Plans

Douglas County MA Plans

Fall River County MA Plans

Haakon County MA Plans

Hanson County MA Plans

Hutchinson County MA Plans

Jackson County MA Plans

Jerauld County MA Plans

Kingsbury County MA Plans

Lake County MA Plans

Lawrence County MA Plans

Lincoln County MA Plans

Marshall County MA Plans

McCook County MA Plans

Meade County MA Plans

Miner County MA Plans

Minnehaha County MA Plans

Moody County MA Plans

Pennington County MA Plans

Roberts County MA Plans

Sanborn County MA Plans

Turner County MA Plans

Union County MA Plans

Yankton County MA Plans



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How much does Blue Medicare Advantage PPO (PPO) cost?

Wellmark Advantage Health Plan charges a $19.00 consolidated monthly premium. A monthly premium is the fee you pay to the plan in exchange for coverage of Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

How much is Blue Medicare Advantage PPO (PPO) MOOP?

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Blue Medicare Advantage PPO (PPO) by Wellmark Advantage Health Plan MOOP is $4,200. Once you spend $4,200 you will pay nothing for Part A or Part B covered services.

What type of plan is Blue Medicare Advantage PPO (PPO)?

Blue Medicare Advantage PPO (PPO) is a Local PPO. A (PPO) is a Medicare plan that has contracts with a network of preferred providers. You do not need to select a primary care physician and you do not need referrals to see other providers in the network.



Source:CMS. Data as of Oct 1, 2022.

Last updated on

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

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