A non-government entity
Independence Health Group, Inc.
Plan ID: H3909-9-0
Plan Summary PagePersonal Choice 65 Rx (PPO)
2025 Personal Choice 65 Rx (PPO) H3909 — 009 — 0 is a Medicare Advantage plan with drug coverage. It has received a 4-out-of-5 star rating from CMS for 2025.
Learn more about Personal Choice 65 Rx (PPO) H3909 - 009 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.
4 / 5 stars for 2025
$152.00 /mo
Monthly premium
$0
Drug deductible
$8950.00
Out-of-pocket maximum (Combined)
Enroll online
Call to enroll
OR
Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!
Plan Overview
2025 Personal Choice 65 Rx (PPO) H3909 — 009 — 0 is a PPO offered in Chester, Delaware, Montgomery Counties by Independence Health Group, Inc.. It has a monthly premium of $152.00.
Premium Breakdown
Standard Part B Premium
$185.00
Part B premium reduction
- $0
Monthly Plan Premium
$152.00
Total Premium:
$337.00
Note:
The standard Medicare Part B premium for 2025 is $185.00. Your premium may differ based on factors like late enrollment, income (IRMAA), or disability status. Most people enrolled in Medicare Part B are required to pay this premium.
Special needs plan type
No
Out-of-pocket maximum (In-Network)
N/A
Out-of-pocket maximum (Out-of-Network)
$5500.00
Out-of-pocket maximum (Combined)
$8950.00
Plan Organization:
Independence Health Group, Inc.
Plan Type:
PPO
Location:
Chester, Delaware, Montgomery Counties
Drugs Covered:
Yes
Drug Formulary:
Pharmacies:
Doctors Link:
Deductibles
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Drug deductible
$0
Sign up for Personal Choice 65 Rx (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
Personal Choice 65 Rx (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Benefit Type
Enhanced Alternative
Prescription drug deductible
$0
Part D Premium Reduction
This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.
Part D | LIS Full |
|---|---|
$60.10 | $11.70 |
Initial Coverage Phase
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2000.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Preferred Pharmacy | Standard Pharmacy | Preferred Mail | Standard Mail |
|---|---|---|---|---|
1. Preferred Generic | $0.00 copay | $20.00 copay | - | $0.00 copay |
2. Standard Generic | 25% coinsurance | 25% coinsurance | - | 25% coinsurance |
3. Preferred Brand | 50% coinsurance | 50% coinsurance | - | 50% coinsurance |
4. Non-Preferred Drug | 33% coinsurance | 33% coinsurance | - | 33% coinsurance |
5. Specialty Tier | - | - | - | - |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
Personal Choice 65 Rx (PPO) also provides the following benefits.
Inpatient Hospital
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute
Inpatient Hospital-Acute benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
Cost Sharing:
| Days 1-6: | Days 7-90: | |
|---|---|---|
| Copayment | 240.00 | 0.00 |
More Details:
Enhanced benefits
Non-Medicare-covered Stay
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
0.00
Periodicity
Every Stay
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
No
Additional Days for Inpatient Hospital-Acute
Additional Days for Inpatient Hospital-Acute benefits are covered.
| Days 91-999: | |
|---|---|
| Copayment | 0.00 |
More Details:
Is this benefit unlimited?
Yes
Number of day intervals for Additional Days
One
Non-Medicare-covered Stay for Inpatient Hospital-Acute
Not covered.
Upgrades for Inpatient Hospital-Acute
Not covered.
Inpatient Hospital Psychiatric
Inpatient Hospital Psychiatric benefits are covered. Prior Authorization is required.
Cost Sharing:
| Days 1-6: | Days 7-90: | |
|---|---|---|
| Copayment | 240.00 | 0.00 |
More Details:
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
0.00
Maximum enrollee out-of-pocket cost type
Plan-specified amount per period
Periodicity
Every Stay
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
No
Additional Days for Inpatient Hospital Psychiatric
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital Psychiatric
Not covered.
Outpatient Services
Outpatient Services benefits are covered.
All Outpatient Hospital Services
All Outpatient Hospital Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Copayment
Medicare-covered Outpatient Hospital Services, Medicare-covered Observation Services
Outpatient Hospital Services
Outpatient Hospital Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Observation Services
Observation Services benefits are covered.
Cost Sharing:
More Details:
Periodicity
Per stay
Ambulatory Surgical Center (ASC) Services
Ambulatory Surgical Center (ASC) Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Outpatient Substance Abuse Services
Outpatient Substance Abuse Services benefits are covered.
Cost Sharing:
More Details:
Which Outpatient Substance Abuse services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Outpatient Substance Abuse
Individual Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
30.00
Maximum copayment
30.00
Group Sessions for Outpatient Substance Abuse
Group Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
20.00
Maximum copayment
20.00
Outpatient Blood Services
Outpatient Blood Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Enhanced benefit
Three (3) Pint Deductible Waived
Partial Hospitalization
Partial Hospitalization benefits are covered. Prior Authorization is required.
Cost Sharing:
Ambulance and Transportation Services
Ambulance and Transportation Services benefits are covered.
All Ambulance Services
All Ambulance Services benefits are covered. Prior Authorization is required.
More Details:
Is there a coinsurance?
No
Is there a copayment ?
Yes
Which Services have a Copayment
Medicare-covered Ground Ambulance Services, Medicare-covered Air Ambulance Services
Is this Copayment waived if admitted to hospital?
No
Ground Ambulance Services
Ground Ambulance Services benefits are covered.
Cost Sharing:
Air Ambulance Services
Air Ambulance Services benefits are covered.
Cost Sharing:
Transportation Services
Transportation Services benefits are covered.
Transportation Services - Plan Approved Health-related Location
Not covered.
Transportation Services - Any Health-related Location
Not covered.
Emergency Services
Emergency Services benefits are covered.
Emergency Services
Emergency Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment?
Yes
Is the copayment for Medicare-covered benefits waived if admitted to hospital?
No
Does the cost sharing count towards any plan-level deductible?
No
Urgently Needed Services
Urgently Needed Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment?
Yes
Is the copayment for Medicare-covered benefits waived if admitted to hospital?
No
Does the cost sharing count towards any plan-level deductible?
No
Worldwide Emergency Services
Worldwide Emergency Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Worldwide Services have a Copayment
Worldwide Urgent Coverage, Worldwide Emergency Transportation
Is there a maximum plan benefit coverage?
No
Worldwide Emergency Coverage
Worldwide Emergency Coverage benefits are covered.
Cost Sharing:
Worldwide Urgent Coverage
Worldwide Urgent Coverage benefits are covered.
Cost Sharing:
Worldwide Emergency Transportation
Not covered.
Primary Care
Primary Care benefits are covered.
Primary Care Physician Services
Primary Care Physician Services benefits are covered.
Cost Sharing:
Chiropractic Services
Chiropractic Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Chiropractic Services have a Copayment
Routine Care, Other
Is there a maximum plan benefit coverage amount?
No
Routine Chiropractic Care
Routine Chiropractic Care benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No, indicate number
Visits
6
Periodicity
Every year
Occupational Therapy Services
Occupational Therapy Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a copayment ?
Yes
Minimum copayment
20.00
Maximum copayment
20.00
Authorization required for this benefit?
No
Referral required for this benefit?
No
Physician Specialist Services
Physician Specialist Services benefits are covered.
Cost Sharing:
Mental Health Specialty Services
Mental Health Specialty Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Mental Health Specialty Services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Mental Health Specialty Services
Individual Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum copayment
30.00
Maximum copayment
30.00
Group Sessions for Mental Health Specialty Services
Group Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum copayment
20.00
Maximum copayment
20.00
Podiatry Services
Podiatry Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Enhanced benefits (7f)
Routine Foot Care
Is this benefit unlimited?
No
Visits
6
Periodicity
Every year
Which Podiatry Services have a Copayment
Medicare-covered Podiatry Services, Routine Foot Care
Minimum copayment
20.00
Maximum copayment
20.00
Minimum copayment
20.00
Maximum copayment
20.00
Is there a maximum plan benefit coverage amount?
No
Other Health Care Professional
Other Health Care Professional benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
0.00
Maximum copayment
35.00
Psychiatric Services
Psychiatric Services benefits are covered.
Cost Sharing:
More Details:
Which Psychiatric Services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Psychiatric Services
Individual Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum copayment
30.00
Maximum copayment
30.00
Group Sessions for Psychiatric Services
Group Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum copayment
20.00
Maximum copayment
20.00
Physical Therapy and Speech-Language Pathology Services
Physical Therapy and Speech-Language Pathology Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment ?
Yes
Authorization required for this benefit?
No
Referral required for this benefit?
No
Additional Telehealth Benefits
Additional Telehealth Benefits benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Medicare-covered benefits that may have Additional Telehealth Benefits available
7a: Primary Care Physician Services, 7c: Occupational Therapy Services, 7d: Physician Specialist Services, 7g: Other Health Care Professional, 7i: Physical Therapy and Speech-Language Pathology Services
Opioid Treatment Program Services
Opioid Treatment Program Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
5.00
Maximum copayment
5.00
Preventive Services
Preventive Services benefits are covered.
Medicare-covered Zero Dollar Preventive Services
Medicare-covered Zero Dollar Preventive Services benefits are covered. Prior Authorization is required.
Annual Physical Exam
Annual Physical Exam benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Is there a maximum plan benefit coverage amount?
No
Additional Preventive Services
Additional Preventive Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Other Defined Supplemental Benefits have a Copayment
14c1: Health Education, 14c4: Fitness Benefit*, 14c5: Enhanced Disease Management, 14c7: Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)*, 14c12: Medical Nutrition Therapy (MNT), 14c20: Home-Based Palliative Care, 14c22: Support for Caregivers of Enrollees
Is there a service-specific Maximum Plan Benefit Coverage amount for Other Defined Supplemental Benefits?
No
Health Education
Health Education benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
In-Home Safety Assessment
Not covered.
Personal Emergency Response System (PERS)
Not covered.
Medical Nutrition Therapy (MNT)
Medical Nutrition Therapy (MNT) benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Do you offer Additional Sessions for Medicare-covered diseases?
Yes
Limit for additional sessions
Sessions
Numerical limit
4
Do you offer Coverage for Non-Medicare-covered diseases?
Yes
Numerical limit
Sessions
Limit for additional sessions
4
Post discharge In-Home Medication Reconciliation
Not covered.
Re-admission Prevention
Not covered.
Wigs for Hair Loss Related to Chemotherapy
Not covered.
Weight Management Programs
Not covered.
Alternative Therapies
Not covered.
Therapeutic Massage
Not covered.
Adult Day Health Services
Not covered.
Nutritional/Dietary Benefit
Not covered.
Home-Based Palliative Care
Home-Based Palliative Care benefits are covered.
More Details:
Type of benefit for Home-Based Palliative Care
Mandatory
Minimum copayment
0.00
Maximum copayment
0.00
In-Home Support Services
Not covered.
Support for Caregivers of Enrollees
Support for Caregivers of Enrollees benefits are covered.
More Details:
Type of benefit for Support for Caregivers of Enrollees
Mandatory
Minimum copayment
0.00
Maximum copayment
0.00
Type of benefit offered for Support for Caregivers of Enrollees
Respite Care, Other
Description
#14c22 Support for Caregivers includes support services (counseling, navigation and support), digital coaching, and education for enrollees and their caregivers.
Additional Sessions of Smoking and Tobacco Cessation Counseling
Not covered.
Fitness Benefit
Fitness Benefit benefits are covered.
More Details:
Type of Fitness Benefit offered
Memory Fitness, Activity Tracker
Minimum copayment
0.00
Maximum copayment
0.00
Enhanced Disease Management
Enhanced Disease Management benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Telemonitoring Services
Not covered.
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Minimum copayment
0.00
Maximum copayment
0.00
Home and Bathroom Safety Devices and Modifications
Not covered.
Counseling Services
Not covered.
Kidney Disease Education Services
Kidney Disease Education Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Other Preventive Services
Other Preventive Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Copayment
Medicare-covered Glaucoma Screening, Medicare-covered Diabetes Self-Management Training, Medicare-covered Barium Enemas, Medicare-covered Digital Rectal Exams, Medicare-covered EKG following Welcome Visit
Is a referral required for any Services?
No
Glaucoma Screening
Glaucoma Screening benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Diabetes Self-Management Training
Diabetes Self-Management Training benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Barium Enemas
Barium Enemas benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Digital Rectal Exams
Digital Rectal Exams benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
EKG following Welcome Visit
EKG following Welcome Visit benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Hearing Services
Hearing Services benefits are covered.
Hearing Exams
Hearing Exams benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Hearing Exam Benefits have a Copayment
Medicare-covered Benefits, Routine Hearing Exams, Fitting/Evaluation for Hearing Aid
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Routine Hearing Exams
Routine Hearing Exams benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Minimum copayment
0.00
Maximum copayment
0.00
Fitting/Evaluation for Hearing Aid
Fitting/Evaluation for Hearing Aid benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Minimum copayment
0.00
Maximum copayment
0.00
Prescription Hearing Aids
Prescription Hearing Aids benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Service maximum plan benefit coverage
No
Prescription Hearing Aids (all types)
Prescription Hearing Aids (all types) benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
2
Periodicity
Every year
Minimum copayment
499.00
Maximum copayment
799.00
Prescription Hearing Aids - Inner Ear
Not covered.
Prescription Hearing Aids - Outer Ear
Not covered.
Prescription Hearing Aids - Over the Ear
Not covered.
OTC Hearing Aids
Not covered.
Vision Services
Vision Services benefits are covered.
Eye Exams
Eye Exams benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Eye Exams have a Copayment
Routine Eye Exams, Other
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Routine Eye Exams
Routine Eye Exams benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Eyewear
Eyewear benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
Yes
Does the Maximum Plan Benefit Coverage amount apply to In-network services only OR does it apply to both In-network and Out-of-network services?
Both In-network and Out-of-network services
Maximum plan benefit coverage type
Plan-specified amount per period
Do you offer a Combined Max Plan Benefit Coverage Amount for all Eyewear?
Yes
Combined maximum amount
250.00
Periodicity
Every year
Contact Lenses
Contact Lenses benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of pairs
1
Periodicity
Every year
Eyeglasses (lenses and frames)
Eyeglasses (lenses and frames) benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of pairs
1
Periodicity
Every year
Eyeglass lenses
Not covered.
Eyeglass frames
Not covered.
Upgrades
Not covered.
Dental Services
Dental Services benefits are covered.
Medicare Dental Services
Medicare Dental Services benefits are covered.
Cost Sharing:
Other Dental Services
Other Dental Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
No
Oral Exams
Oral Exams benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Subject to limitations described in note
Dental X-Rays
Dental X-Rays benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of X-Rays
1
Periodicity
Other, Describe
Description
#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.
Prophylaxis (Cleaning)
Prophylaxis (Cleaning) benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Every six months
Fluoride Treatment
Fluoride Treatment benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Every year
Orthodontic Services
Orthodontic Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
Yes
Maximum plan benefit coverage type
Plan-specified amount per period
Does the maximum plan benefit coverage amount apply to in-network services only or does it apply to both in-network and out-of-network services
Both in-network and out-of-network services
Maximum amount
1500.00
Periodicity
Every year
Restorative Services
Restorative Services benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.
Coinsurance percentage
20
Adjunctive General Services
Adjunctive General Services benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Endodontics
Endodontics benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.
Coinsurance percentage
20
Periodontics
Periodontics benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.
Coinsurance percentage
20
Prosthodontics, removable
Prosthodontics, removable benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life
Coinsurance percentage
40
Maxillofacial Prosthetics
Not covered.
Implant Services
Implant Services benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
#16c6, Implant Services: 1 implant per tooth every 5 years.
Coinsurance percentage
40
Prosthodontics, fixed
Prosthodontics, fixed benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.
Coinsurance percentage
40
Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Orthodontics
Not covered.
Home Infusion bundled Services
Home Infusion bundled Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Medicare Part B Rx Drugs have a Coinsurance
Medicare Part B Chemotherapy/Radiation Drugs, Other Medicare Part B Drugs
Does this plan have a service specific maximum enrollee out-of-pocket cost (MOOP)?
No
Does the plan offer step therapy?
Yes
Does the benefit step from?
Part B to Part D
Does the plan provide Part D home infusion drugs as part of a bundled service as a mandatory supplemental benefit?
No
Insulin
Insulin benefits are covered.
Medicare Part B Insulin Drugs
Medicare Part B Insulin Drugs benefits are covered.
Cost Sharing:
More Details:
Does the Part B drugs - Insulin cost sharing count towards any plan-level deductible?
No
Medicare Part B Chemotherapy/Radiation Drugs
Medicare Part B Chemotherapy/Radiation Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Other Medicare Part B Drugs
Other Medicare Part B Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Dialysis Services
Dialysis Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Equipment
Medical Equipment benefits are covered.
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) benefits are covered.
More Details:
Is there a coinsurance?
Yes
Minimum coinsurance
20
Maximum coinsurance
20
Is there a copayment ?
No
Are there preferred vendors/manufacturers for Durable Medical Equipment (DME)?
No
Authorization required for this benefit?
Yes
Durable Medical Equipment for use outside the home
Not covered.
Prosthetics/Medical Supplies - Non-Medicare benefit
Prosthetics/Medical Supplies - Non-Medicare benefit benefits are covered.
More Details:
Is there a coinsurance?
Yes
Which Prosthetics/Medical Supplies have a Coinsurance
Medicare-covered Prosthetic Devices, Medicare-covered Medical Supplies
Is there a copayment ?
No
Authorization required for this benefit?
Yes
Prosthetic Devices
Prosthetic Devices benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Supplies
Medical Supplies benefits are covered.
Cost Sharing:
Diabetic Equipment
Diabetic Equipment benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Diabetic Supplies and Services have a Coinsurance
Medicare-covered Diabetic Therapeutic Shoes or Inserts
Which Diabetic Supplies and Services have a Copayment
Medicare-covered Diabetes Supplies
Do you limit Diabetic supplies and services to those from specified manufacturers
Yes
Diabetic Supplies
Diabetic Supplies benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Diabetic Therapeutic Shoes/Inserts
Diabetic Therapeutic Shoes/Inserts benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Diagnostic and Radiological Services
Diagnostic and Radiological Services benefits are covered.
All Diagnostic services
All Diagnostic services benefits are covered. Prior Authorization is required.
More Details:
Is there a copayment?
Yes
Which Outpatient Diagnostic Procedures/Tests/Lab Services have a Copayment
Medicare-covered Diagnostic Procedures/Tests, Medicare-covered Lab Services
If a member receives multiple services at the same location on the same day, does only the maximum copay apply?
Yes
Diagnostic Procedures/Tests
Diagnostic Procedures/Tests benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Lab Services
Lab Services benefits are covered.
Cost Sharing:
All Radiological Services
All Radiological Services benefits are covered. Prior Authorization is required.
More Details:
Is there a copayment?
Yes
Which Outpatient Diagnostic/Therapeutic Radiological Services have a Copayment
Medicare-covered Diagnostic Radiological Services, Medicare-covered Therapeutic Radiological Services, Medicare-covered X-Ray Services
If a member receives multiple services at the same location on the same day, does only the maximum copay apply?
Yes
Diagnostic Radiological Services
Diagnostic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
0.00
Therapeutic Radiological Services
Therapeutic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
80.00
Outpatient X-Ray Services
Outpatient X-Ray Services benefits are covered.
Cost Sharing:
Home Health Services
Home Health Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment ?
Yes
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Additional Hours of Care
Not covered.
Personal Care Services
Not covered.
Cardiac Rehabilitation Services
Cardiac Rehabilitation Services benefits are covered.
Cost Sharing:
More Details:
Which Cardiac and Pulmonary Rehabilitation Services have a Copayment
Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, Additional Cardiac Rehabilitation Services
Cardiac Rehabilitation Services
Not covered.
Intensive Cardiac Rehabilitation Services
Not covered.
Pulmonary Rehabilitation Services
Not covered.
SET for PAD Services
Not covered.
Skilled Nursing Facility (SNF)
Skilled Nursing Facility (SNF) benefits are covered. Prior Authorization is required.
Cost Sharing:
| Days 1-20: | Days 21-100: | |
|---|---|---|
| Copayment | 0.00 | 214.00 |
More Details:
Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?
No
Do you allow less than 3 day inpatient hospital stay prior to SNF admission?
Yes
Days
Zero
Do you charge the Medicare-defined cost share for tier 1?
No
Periodicity
Original Medicare
Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF)
Not covered.
Non-Medicare-covered Stay for Skilled Nursing Facility (SNF)
Not covered.
Other Services
Other Services benefits are covered.
Acupuncture
Acupuncture benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Is this benefit unlimited for Number of Treatments?
No
Limit for Number of Treatments
6
Periodicity
Every year
Is there a maximum plan benefit coverage amount?
No
Over-the-Counter (OTC) Items
Over-the-Counter (OTC) Items benefits are covered.
More Details:
Does the plan provide Over-The-Counter (OTC) Items as a supplemental benefit under Part C?
Yes
Is there a maximum plan benefit coverage amount?
Yes
Maximum plan benefit coverage amount
30.00
Periodicity
Every three months
Does your Maximum Plan Benefit Coverage amount carry forward to the next period if it is unused?
No
Plan offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit?
No
Plan offers Naloxone coverage as a Part C OTC benefit?
Yes
Does this cover all of the drugs on the CMS OTC list which may be found in Chapter 4 of the Medicare Managed Care Manual
No
Meal Benefit
Not covered.
Dual Eligible SNPs with Highly Integrated Services
Not covered.
Other Services
Other Services benefits are covered.
More Details:
Is Authorization required for one or more Additional Services?
No
Is a referral required for one or more Additional Services?
No
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services
Not covered.
Private Duty Nursing Services
Not covered.
Case Management (Long Term Care)
Not covered.
Institution for Mental Disease Services for Individuals 65 or Older
Not covered.
Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities
Not covered.
Case Management
Not covered.
Tobacco Cessation Counseling for Pregnant Women
Not covered.
Freestanding Birth Center Services
Not covered.
Respiratory Care Services
Not covered.
Family Planning Services
Not covered.
Nursing Home Services
Not covered.
Home and Community Based Services
Not covered.
Personal Care Services
Not covered.
Self-Directed Personal Assistance Services
Not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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