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Blue Medicare Advantage Enhanced PPO (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Medicare Advantage Enhanced 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 Enhanced PPO (PPO) in 2025, please refer to our full plan details page.
Blue Medicare Advantage Enhanced 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 Enhanced 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 Enhanced 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 Enhanced PPO (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $63.00. 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 $3800.00 (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 $3800.00 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 Enhanced PPO (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, for preferred generic drugs, you'll pay a $12 copay at standard and mail-order pharmacies. For standard generic drugs, you'll pay a $47 copay, and for preferred brand drugs, you'll pay 50% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you will pay nothing for Part D covered drugs.
Additional Benefits
The Blue Medicare Advantage Enhanced PPO (PPO) plan offers comprehensive coverage, including inpatient hospital stays with a $425 copay, outpatient services with varying copays, and emergency services with a $120 copay. It also includes coverage for primary care with no copay for primary care physician services, preventive services with no copay for annual physical exams and other benefits, and hearing and vision services, including hearing exams with no copay and routine eye exams with no copay to $30. Dental services, home infusion, dialysis, and medical equipment are also covered with varying copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered, with a copay of $425 for a Medicare-covered stay. Additional days for Inpatient Hospital-Acute are also 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, including Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, Outpatient Substance Abuse Services, and Outpatient Blood Services, are covered. Outpatient Hospital Services have a copay of $30-$200, Observation Services have a $250 copay, Ambulatory Surgical Center (ASC) Services have a $175 copay, and both Individual and Group Sessions for Outpatient Substance Abuse have a copay of $30. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Blue Medicare Advantage Enhanced PPO (PPO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
For the Blue Medicare Advantage Enhanced PPO (PPO) plan, ambulance services are covered with a $325 copay for both ground and air ambulance services, and there is no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Blue Medicare Advantage Enhanced PPO (PPO) plan with a $120 copay, and Urgently Needed Services have a $45 copay. Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are also covered, with copays of $120 and $325 respectively, and a maximum plan benefit of $50,000.
Primary Care See details
Primary Care includes coverage for Primary Care Physician Services with no copay, Chiropractic Services with a $20 copay, Occupational Therapy Services with a $20 copay, Physician Specialist Services with a $30 copay, Mental Health Specialty Services with a $30 copay, Other Health Care Professional with a copay between $0 and $30, Psychiatric Services with a $30 copay, Physical Therapy and Speech-Language Pathology Services with a $20 copay, Additional Telehealth Benefits with a copay between $0 and $45, and Opioid Treatment Program Services with no copay. Podiatry Services are not covered.
Preventive Services See details
The Blue Medicare Advantage Enhanced PPO (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, including Fitness Benefit, Personal Emergency Response System (PERS), and Remote Access Technologies, are covered with no copay. Other services such as Health Education, In-Home Safety Assessment, Medical Nutrition Therapy (MNT), and others are not covered.
Hearing Services See details
The Blue Medicare Advantage Enhanced PPO (PPO) plan offers hearing services, including hearing exams with no copay. Prescription hearing aids are covered up to $500 per ear annually, while OTC hearing aids are covered up to $50 per ear every three months. Prescription hearing aids for inner ear, outer ear, and over the ear are not covered.
Vision Services See details
The Blue Medicare Advantage Enhanced PPO (PPO) plan covers vision services, including routine eye exams with a copay of $0-$30. Contact lenses are covered with a maximum benefit of $100 every year, while eyeglass lenses and frames are covered for one pair every year. Eyeglass frames and upgrades are also covered.
Dental Services See details
The Blue Medicare Advantage Enhanced PPO (PPO) plan covers Medicare Dental Services with a $30 copay, and other dental services including oral exams, dental x-rays, prophylaxis (cleaning), fluoride treatment, and orthodontics services are covered. Restorative services are covered with 25% - 50% coinsurance, endodontics with 50% coinsurance, and prosthodontics, removable with 50% coinsurance, and implant services with 50% coinsurance, while maxillofacial prosthetics and orthodontics are not covered. Oral and maxillofacial surgery is covered with 0% - 50% coinsurance.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Blue Medicare Advantage Enhanced PPO (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered by the Blue Medicare Advantage Enhanced PPO (PPO) plan, including Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Equipment with no copay and no coinsurance for Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures and tests with a $30 copay, lab services with no copay, and outpatient X-ray services with a $10 copay. Therapeutic Radiological Services have a 20% coinsurance, and Diagnostic Radiological Services have a $125 copay.
Home Health Services See details
Home Health Services are covered by the Blue Medicare Advantage Enhanced PPO (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Blue Medicare Advantage Enhanced PPO (PPO) plan. No copay or coinsurance information is available, since the services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Blue Medicare Advantage Enhanced PPO (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $200.
Other Services See details
The Blue Medicare Advantage Enhanced PPO (PPO) plan's Other Services benefit covers Over-the-Counter (OTC) Items with a maximum benefit of $50 every three months, as well as a Meal Benefit with no copay, but requires prior authorization. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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