Personal Choice 65SM PPO

2013 Prescription Coverage

The Personal Choice 65 Rx PPO is a Medicare supplement that includes Medicare Part D prescription drug coverage. If you choose to enroll in this plan:

  • You’ll 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 ID card.
  • Your prescriptions will be covered at out-of-network pharmacies in special circumstances while traveling within the United States. You will need to pay the entire cost of the drug, and we will reimburse you the full amount minus the applicable cost-sharing.

How the Personal Choice Rx Option works:

The chart below provides an explanation of how the Part D coverage works for the Personal Choice 65 Rx PPO option:

Personal Choice 65 Rx PPO

Deductible

$285 yearly deductible

Copay

After you meet the yearly deductible you will pay:
  • $5 for generics
  • $40 for preferred brand
  • $80 for non-preferred brand
  • 25% for specialty drugs

Coverage Gap

Once your total yearly drug costs reach $2,970, you pay 79% for generic drugs and 47.5% for brand name drugs.

Catastrophic Coverage

After you reach $4,750, you pay the greater of either:
  • $2.65 for generic drugs and $6.60 for all other drugs;
Or
  • 5% of your drug costs.

Contact Us

  • Prospective 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.
  • Members can call 1-888-718-3333 (1-888-857-4816 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week.
  • Send us an email.
  • Prospective members can mail any inquiries to P.O. Box 13713, Philadelphia, PA 19101-3713.
  • Members can mail any inquiries to P.O. Box 7799, Philadelphia, PA 19101-7799.

Summary of Benefits

For details of covered services, copays, and deductibles for Personal Choice 65 PPO plans, see the PDF icon Summary of Benefits Y0041_H3909_PC_13_2338 Accepted 09/22/2012


Website last updated: 09/30/2013
Y0041_HM_14_9866 Approved 11/5/2013