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Blue Medicare Advantage PPO (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Medicare Advantage PPO (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Medicare Advantage PPO (PPO) in 2025, please refer to our full plan details page.
Blue Medicare Advantage PPO (PPO) is a PPO plan offered by Blue Cross Blue Shield of Michigan Mutual Ins. Co. available for enrollment in 2025 to people living in South Dakota. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Blue Medicare Advantage PPO (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Blue Medicare Advantage PPO (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Blue Medicare Advantage PPO (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $22.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $4200.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $4200.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Blue Medicare Advantage PPO (PPO) plan has an enhanced alternative drug benefit. The plan has a $0 deductible. In the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy type. For example, standard generic drugs have a $12 copay, while preferred brand drugs have 50% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Blue Medicare Advantage PPO (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay of $300 for the first six days, with no copay for the remainder, while outpatient services range from no copay to $350 depending on the service. The plan also includes coverage for emergency services, primary care, preventive services, hearing, vision, and dental services, all with differing copays or coinsurance amounts. This plan provides additional benefits such as ambulance services with a $350 copay, home health services with no copay, and medical equipment with coinsurance. The plan also covers skilled nursing facilities, with no copay for the first 20 days, and $203 per day for days 21-100. Additionally, there are benefits for over-the-counter items and meal benefits, both with no copay and requiring prior authorization.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $300 copay for days 1-6, and no copay for days 7-90. For Inpatient Hospital Psychiatric, you will pay a $300 copay for days 1-6, and no copay for days 7-90. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay of $45 to $350, observation services with a $275 copay, ambulatory surgical center services with a $250 copay, outpatient substance abuse services with a $45 copay for individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Medicare Advantage PPO (PPO) plan. This benefit requires prior authorization and has a copay of $85.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Blue Medicare Advantage PPO (PPO) plan, including both ground and air ambulance services with a $350 copay and no coinsurance. However, transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Blue Medicare Advantage PPO (PPO) plan. Emergency Services has a $125 copay, while Urgently Needed Services has a $50 copay. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $120 copay, and Worldwide Emergency Transportation has a $350 copay.
Primary Care See details
Primary Care Physician Services are covered with no copay. Chiropractic services, including routine care, are covered; routine care has a $30 copay, and other chiropractic services have a $20 copay. Occupational therapy services have a $45 copay. Physician specialist services, physical therapy, and speech-language pathology services each have a $45 copay. Mental health specialty services, psychiatric services, and Opioid Treatment Program Services have a $45 copay for individual and group sessions. Other Health Care Professional services are covered with a copay that ranges from $0 to $45. Additional telehealth benefits are covered with a copay ranging from $0 to $50. Podiatry services are not covered.
Preventive Services See details
Preventive services include no copay for an annual physical exam and also include no copay for glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. Other services, like health education, are not covered.
Hearing Services See details
Hearing Services include hearing exams with no copay, Routine Hearing Exams, and Fitting/Evaluation for Hearing Aid, each covered once per year. Prescription Hearing Aids are covered with a maximum benefit of $500 per year, per ear, and OTC Hearing Aids are covered up to $50 per ear every three months. Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered.
Vision Services See details
The Blue Medicare Advantage PPO (PPO) plan covers vision services, including routine eye exams with a copay between $0 and $45. The plan also covers eyewear such as contact lenses, eyeglass lenses, and eyeglass frames. Contact lenses are covered up to $100 every year, and eyeglass frames are covered up to $100 every year. Eyeglasses (lenses and frames) are not covered.
Dental Services See details
The Blue Medicare Advantage PPO (PPO) plan covers Medicare dental services with a $45 copay, and other dental services with a $15 copay. The plan also covers Oral Exams, Dental X-Rays, Prophylaxis (Cleaning), Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Implant Services, and Oral and Maxillofacial Surgery, and Orthodontic services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered under the Blue Medicare Advantage PPO (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, is covered by the Blue Medicare Advantage PPO (PPO) plan. Durable Medical Equipment has a coinsurance of 0-20%, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices, Medical Supplies, and Diabetic Supplies have a 20% coinsurance, while Diabetic Therapeutic Shoes/Inserts and Diabetic Supplies have no coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic and radiological services. Diagnostic Procedures/Tests have a $45 copay, and Lab Services have a $5 copay. Diagnostic Radiological Services have a copay of at most $100, while Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the Blue Medicare Advantage PPO (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Blue Medicare Advantage PPO (PPO) plan, but the specific services of Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD are not covered. There is a copay for some services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Blue Medicare Advantage PPO (PPO) plan, but require prior authorization. You will have no copay for days 1-20, and a $203 copay per day for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Blue Medicare Advantage PPO (PPO) plan's "Other Services" benefit includes Over-the-Counter (OTC) Items with a maximum benefit of $50 every three months, and Meal Benefits with no copay, but requires prior authorization. Acupuncture and several other services are not covered.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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