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Blue Medicare Advantage Enhanced PPO (PPO)

H5900 - 004 - 0
4.5 out of 5 stars (4.5 / 5)

Blue Medicare Advantage Enhanced PPO (PPO) is a Medicare Advantage Plan by Wellmark Advantage Health Plan.

This page features plan details for 2025 Blue Medicare Advantage Enhanced PPO (PPO) H5900 – 004 – 0 available in South Dakota.

Locations

Blue Medicare Advantage Enhanced PPO (PPO) is offered in the following locations.

Aurora County, South Dakota
Bon Homme County, South Dakota
Brookings County, South Dakota

Click to see more locations

Plan Overview

Blue Medicare Advantage Enhanced PPO (PPO) offers the following coverage and cost-sharing.

Insurer:Wellmark Advantage Health Plan
Health Plan Deductible:$0
MOOP:$3,800 In and Out-of-network
$3,800 In-network
Drugs Covered:Yes

Ready to sign up for Blue Medicare Advantage Enhanced PPO (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Blue Medicare Advantage Enhanced PPO (PPO) has a monthly premium of $63.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $63.00 $0.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Blue Medicare Advantage Enhanced PPO (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

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 $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, 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. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Blue Medicare Advantage Enhanced PPO (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Endodontics
    • In-Network: 50 Coins – No Co pay
  • Implant Services
    • In-Network: 50 Coins – No Co pay
  • Oral and Maxillofacial Surgery
    • In-Network: 0-50 Coins – No Co pay (Limits Apply)
  • Periodontics
    • In-Network: 0-50 Coins – No Co pay
  • Prosthodontics, fixed
    • In-Network: 50 Coins – No Co pay
  • Prosthodontics, removable
    • In-Network: 50 Coins – No Co pay
  • Restorative Services
    • In-Network: 25-50 Coins – No Co pay

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
    • Out-of-Network: No Coins – 0.00 Copay
  • Fluoride Treatment
    • In-Network: No Coins – No Copay
    • Out-of-Network: No Coins – 0.00 Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
    • Out-of-Network: No Coins – 0.00 Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay
    • Out-of-Network: No Coins – 0.00 Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • In-Network: $30 copay (Authorization Required)
  • Lab services
    • In-Network: $0 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $10 copay (Authorization Required)
    • Out-of-Network: $10 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $125 copay (Authorization Required)
    • Out-of-Network: $125 copay (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: $30 copay (Authorization Required)
  • Lab services
    • Out-of-Network: $0 copay (Authorization Required)

Doctor visits

  • Primary
    • In-Network: $0 copay
    • Out-of-Network: $0 copay
  • Specialist
    • In-Network: $30 copay per visit
    • Out-of-Network: $30 copay per visit

Emergency care/Urgent care

  • Urgent care
    • $45 copay per visit (always covered)
  • Emergency
    • $120 copay per visit (always covered)

Foot care (podiatry services)

  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • In-Network: $35 copay
    • Out-of-Network: $35 copay

Ground ambulance

    • In-Network: $325 copay
    • Out-of-Network: $325 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply)
  • Hearing aids
    • In-Network: $0 copay (Limits Apply)
  • Hearing aids OTC
    • In-Network: $0 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • In-Network: $0-30 copay
  • Fitting/evaluation
    • Out-of-Network: $0 copay (Limits Apply)
  • Hearing aids
    • Out-of-Network: $0 copay (Limits Apply)
  • Hearing aids OTC
    • Out-of-Network: $0 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • Out-of-Network: $0-30 copay

Inpatient hospital coverage

    • In-Network: $425 per stay (Authorization Required)
    • Out-of-Network: $425 per stay (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $3,800 In and Out-of-network
      $3,800 In-network

Medical equipment/supplies

  • Diabetes supplies
    • Out-of-Network: $0 copay
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: $0 copay
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 0-20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • Out-of-Network: 0-20% coinsurance (Authorization Required)
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 0-20% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • Out-of-Network: $425 per stay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $30 copay
    • Out-of-Network: $30 copay
  • Inpatient hospital – psychiatric
    • In-Network: $425 per stay (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $30 copay
    • Out-of-Network: $30 copay
  • Outpatient individual therapy visit
    • Out-of-Network: $30 copay
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $30 copay
  • Outpatient individual therapy visit
    • In-Network: $30 copay
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: $30 copay

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $30-200 copay per visit (Authorization Required)
    • Out-of-Network: $30-200 copay per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • In-Network: $20 copay
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: $20 copay
  • Occupational therapy visit
    • Out-of-Network: $20 copay
  • Physical therapy and speech and language therapy visit
    • In-Network: $20 copay

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $200 per day for days 21 through 100 (Authorization Required)
    • Out-of-Network: $0 per day for days 1 through 20
      $200 per day for days 21 through 100 (Authorization Required)

Transportation

    • Not covered

Vision

  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Not covered
  • Upgrades
    • In-Network: $0 copay (Limits Apply)
  • Contact lenses
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Other
    • Not covered
  • Upgrades
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: 50% coinsurance (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for Blue Medicare Advantage Enhanced PPO (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Blue Medicare Advantage Enhanced PPO (PPO)? See 2025 Blue Medicare Advantage Enhanced PPO (PPO) at MedicareAdvantageRX.com.

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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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