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Blue Medicare Advantage Classic PPO (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Medicare Advantage Classic 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 Classic PPO (PPO) in 2026, please refer to our full plan details page.
Blue Medicare Advantage Classic PPO (PPO) is a PPO plan offered by Blue Cross Blue Shield of Michigan Mutual Ins. Co. available for enrollment in 2026 to people living in South Dakota. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Blue Medicare Advantage Classic 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 Classic 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 Classic PPO (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $55.00. 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 a $300.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6500.00 (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 $6500.00 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 Classic PPO (PPO) prescription drug plan features an annual drug deductible of $300. Under this plan, you will pay no copay for Tier 1 preferred generic drugs filled through standard pharmacies or standard mail order. Tier 2 generic drugs are also highly affordable, costing as little as a $5 copay for a one-month supply at standard pharmacies and mail-order services. For brand-name and specialty medications, your costs are based on coinsurance rates. You will pay a 20% coinsurance for Tier 3 preferred brand drugs and a 25% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs require a 29% coinsurance for a one-month supply through standard pharmacies or mail order.
Additional Benefits
The Blue Medicare Advantage Classic PPO (PPO) offers robust medical coverage with predictable out-of-pocket costs, featuring no copay for primary care visits and a $50 copay for specialists. For hospital care, inpatient stays require a $390 daily copay for days 1 through 6 and no copay for days 7 through 90, while outpatient hospital visits range from a $50 to $400 copay with no coinsurance. Emergency room visits have a $130 copay, which is waived if admitted within 24 hours, and urgent care is available for a $50 copay. Routine preventive services, annual physicals, and home health services are fully covered with no copay and no coinsurance. The plan also includes no copay for routine hearing exams and preventive dental care, while routine vision exams range from no copay to a $50 copay. However, this plan does not cover acupuncture, over-the-counter items, meal benefits, or diabetic supplies, meaning members must pay the full cost for these services.
Inpatient Hospital See details
Blue Medicare Advantage Classic PPO (PPO) partially covers inpatient acute and psychiatric hospital services with no coinsurance, requiring a $390 daily copay for days 1 through 6 and no copay for days 7 through 90. Non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by Blue Medicare Advantage Classic PPO (PPO) with no coinsurance, featuring copays of $50 to $400 for outpatient hospital visits, $300 per stay for observation services, and $250 for ambulatory surgical center services. Outpatient substance abuse sessions require a $50 copay with no coinsurance, while outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
Blue Medicare Advantage Classic PPO (PPO) covers partial hospitalization services with a $140.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Blue Medicare Advantage Classic PPO (PPO) covers ground ambulance services with a $450 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required. Although transportation services are technically covered, specific options like transportation to plan-approved health-related locations and any other health-related locations are not covered.
Emergency Services See details
Blue Medicare Advantage Classic PPO (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgent care with a $50 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are covered up to a $50,000 maximum with no coinsurance, requiring a $130 copay for emergency or urgent care and a $450 copay for transportation.
Primary Care See details
Blue Medicare Advantage Classic PPO (PPO) covers primary care physician services and opioid treatment with no copay and no coinsurance, while specialist visits, physical, occupational, speech, and mental health therapies require a $50 copay and no coinsurance. Podiatry services are not covered, and telehealth benefits are available with a copay ranging from $0 to $50 and no coinsurance.
Preventive Services See details
Blue Medicare Advantage Classic PPO (PPO) covers preventive services, including annual physical exams, kidney disease education, and select screenings, with no copay and no coinsurance. Additional preventive services are partially covered, with remote access technologies included, but sub-services such as fitness benefits, health education, in-home safety assessments, and counseling are not covered.
Hearing Services See details
Blue Medicare Advantage Classic PPO (PPO) covers one routine hearing exam per year with no copay, no coinsurance, and no deductible. Some prescription hearing aid services are covered, but fitting and evaluation, OTC hearing aids, and all prescription hearing aid types (including inner ear, outer ear, and over the ear) are not covered.
Vision Services See details
Vision services are partially covered by the Blue Medicare Advantage Classic PPO (PPO), which features routine eye exams with a $0 to $50 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance, offering up to a $50 annual maximum benefit for contact lenses or eyeglass frames.
Dental Services See details
Blue Medicare Advantage Classic PPO (PPO) provides partially covered dental services, featuring Medicare-covered dental for a $50 copay and no coinsurance, alongside preventive care like exams, cleanings, x-rays, and fluoride with no copay and no coinsurance. However, other diagnostic, other preventive, restorative, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontic services are not covered.
Home Infusion bundled Services See details
Blue Medicare Advantage Classic PPO (PPO) covers Home Infusion bundled Services with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other Part B drugs feature no copay and a 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Blue Medicare Advantage Classic PPO (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is partially covered by the Blue Medicare Advantage Classic PPO (PPO) with no copays and coinsurance ranging from no coinsurance to 20%. Covered items include durable medical equipment, prosthetics, and diabetic therapeutic shoes, but diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Blue Medicare Advantage Classic PPO (PPO) with prior authorization, requiring no coinsurance alongside a $5 copay for lab services and a $50 copay for diagnostic tests. Outpatient X-rays require a $20 copay, diagnostic radiological services have a $150 copay, and therapeutic radiological services incur a 20% coinsurance.
Home Health Services See details
Blue Medicare Advantage Classic PPO (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered with no coinsurance under the Blue Medicare Advantage Classic PPO (PPO), though only some services are covered in practice. Specifically, cardiac rehabilitation (with a $40 copay), intensive cardiac rehabilitation ($50 copay), pulmonary rehabilitation ($35 copay), and supervised exercise therapy for symptomatic peripheral artery disease services ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Blue Medicare Advantage Classic PPO (PPO) covers skilled nursing facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Blue Medicare Advantage Classic PPO (PPO) does not cover Other Services, including acupuncture, over-the-counter (OTC) items, and meal benefits. Because these services are not covered by the plan, members are responsible for the full cost of these items.
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