Personal Choice 65 Medical Only (PPO)
H3909 - 007 - 0
(4.5 / 5)
Personal Choice 65 Medical Only (PPO) is a Medicare Advantage (Part C) Plan by Independence Blue Cross.
This page features plan details for 2024 Personal Choice 65 Medical Only (PPO) H3909 – 007 – 0 available in Bucks, Philadelphia Counties.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Personal Choice 65 Medical Only (PPO) is offered in the following locations.
Plan Overview
Personal Choice 65 Medical Only (PPO) offers the following coverage and cost-sharing.
| Insurer: | Independence Blue Cross |
| Health Plan Deductible: | $0.00 |
| MOOP: | $8,950 In and Out-of-network $5,000 In-network |
| Drugs Covered: | No |
Ready to sign up for Personal Choice 65 Medical Only (PPO) ?
Premium Breakdown
Personal Choice 65 Medical Only (PPO) has a monthly premium of $138.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $138.00 | $0.00 | $312.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Personal Choice 65 Medical Only (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $8,950 In and Out-of-network $5,000 In-network |
| No |
| In-network | Yes, contact plan for further details |
| In-network | $300 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | 30% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | 30% coinsurance per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $35 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | 30% coinsurance per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $5-60 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0-175 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $499-799 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $499-799 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | 80% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | 80% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | 80% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Restorative services | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Restorative services | 80% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Endodontics | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Endodontics | 80% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Periodontics | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Periodontics | 80% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Extractions | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Extractions | 80% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | 40% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | 80% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | 80% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Contact lenses | 80% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | 80% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network | $175 copay (Not applicable.) (Not applicable.) |
| out-of-network | $175 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $20 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Routine foot care | $20 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $240 per day for days 1 through 6 $0 per day for days 7 through 90 $0 per day for days 90 and beyond (Authorization is required.) (Referral is not required.) |
| out-of-network | 30% per stay (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $240 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | 30% per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $20 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $30 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | 30% per stay (Authorization is required.) (Referral is not required.) |
Ready to sign up for Personal Choice 65 Medical Only (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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