TRACKING

Personal Choice 65SM PPO

2013 Overview

Enroll in a plan

Freedom to go to any doctor or hospital in the U.S. — without a referral

With Personal Choice 65 PPO, a Medicare Advantage PPO plan, you’ll get more protection than Original Medicare and a Medicare supplement, and you’ll pay less — or nothing at all — for most preventive care. You can also choose to add prescription drug coverage to your plan.

With Personal Choice 65 PPO:

  • You don’t need to select a primary care physician.
  • You are covered for services in or out of the network, but your costs may be higher when you go out of the network.
  • Referrals are not necessary and there is virtually no paperwork.
  • There is no deductible for in-network care.

Personal Choice 65 PPO plans include:

If you choose to enroll in Personal Choice 65 Rx PPO coverage:

  • You will have the convenience of paying just one premium each month for both your medical and drug coverage.
  • You can go to thousands of pharmacies within the network and simply present your Personal Choice 65 PPO card. Learn more about prescription drug coverage.
  • If you reach the maximum out-of-pocket amount of $6,700 for in-network services and $10,000 for out-of-network services, you will not have to pay any out-of-pocket costs for the rest of the year for in-network and out-of-network covered Part A and Part B services.

Personal Choice 65 PPO MA (medical-only plan) Medical coverage:
  • PCP Visit: $5 copayment; Out-of-Network: 30% coinsurance
  • Specialist Visit: $40 copayment; Out-of-Network: 30% coinsurance
  • Prescription Drugs: Not Covered
  • Emergency Room: $65 copayment - not waived if admitted; Out-of-Network: $65 copayment - not waived if admitted. Emergency room coverage is worldwide.
  • Ambulance: $75 copayment; Out-of-Network: $75 copayment
  • Urgent Care: $20 - In-network Urgent Care Centers; $5 PCP - $40 Specialist; copayment depends on provider type
  • Inpatient Hospital: $850 per admission; Out-of-Network: 30% coinsurance
  • Outpatient Hospital: $0 - $400
  • Preventive Services: $0 copayment; Out-of-Network: 30% coinsurance
  • Health/Wellness Education: Programs include: SilverSneakers, Weight Management, Smoking Cessation, Safety Helmets, and Disease Management
  • Out-of-Network Deductible: $0 - No Deductible
Personal Choice 65 Rx PPO (medical plus prescription drug) Medical coverage + prescription drug coverage:
  • PCP Visit: $5 copayment; Out-of-Network: 30% coinsurance
  • Specialist Visit: $40 copayment; Out-of-Network: 30% coinsurance
  • Prescription Drugs: $285 Deductible; $5 generic/$40 preferred brand/$80 non-preferred brand/25% coinsurance specialty drugs; once you have reached $2,970 in total drug costs you will pay 79% for generic drugs and 47.5% for brand-name drugs. You will pay the greater of $2.65 generic and $6.60 brand or 5% coinsurance after reaching the $4,750 catastrophic stage. Mail order is available.
  • Emergency Room: $65 copayment - not waived if admitted; Out-of-Network: $65 copayment - not waived if admitted. Emergency room coverage is worldwide.
  • Ambulance: $75 copayment; Out-of-Network: $75 copayment
  • Urgent Care: $20 - In-network Urgent Care Centers; $5 PCP - $40 Specialist; copayment depends on provider type
  • Inpatient Hospital: $850 per admission; Out-of-Network: 30% coinsurance
  • Outpatient Hospital: $0 - $400
  • Preventive Services: $0 copayment; Out-of-Network: 30% coinsurance
  • Health/Wellness Education: Programs include: SilverSneakers, Weight Management, Smoking Cessation, Safety Helmets, and Disease Management
  • Out-of-Network Deductible: $0 - No Deductible

Contact Us

  • Prospective Personal Choice 65 PPO members can call 1-877-393-6733 (1-877-219-5457 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week. However, please be aware that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.
  • Prospective members can mail any inquiries to P.O. Box 13713, Philadelphia, PA 19101-3713.
  • Members can call 1-800-645-3965 (1-888-857-4816 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week.
  • Members can mail any inquiries to P.O. Box 7799, Philadelphia, PA 19101-7799
  • Send us an email.

Summary of Benefits

For details of covered services, copays, and deductibles for Personal Choice 65 PPO plans, see the ibxmedicare.com Summary of Benefits Y0041_H3909_PC12_03 CMS Approved 09/09/2011.


Website last updated: 9/30/2013
Y0041_HM_14_9866 Approved 11/5/2013