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Personal Choice 65 Elite Rx (PPO)

H3909 - 017 - 0
4 out of 5 stars (4 / 5)

independence-blue-cross medicare provider logo

Personal Choice 65 Elite Rx (PPO) is a Medicare Advantage Plan by Independence Blue Cross.

This page features plan details for 2025 Personal Choice 65 Elite Rx (PPO) H3909 – 017 – 0 available in Philadelphia, Bucks, Chester, Delaware, Montgomery.

Locations

Personal Choice 65 Elite Rx (PPO) is offered in the following locations.

Bucks County, Pennsylvania
Chester County, Pennsylvania
Delaware County, Pennsylvania

Click to see more locations

Plan Overview

Personal Choice 65 Elite Rx (PPO) offers the following coverage and cost-sharing.

Insurer:Independence Blue Cross
Health Plan Deductible:$0
MOOP:$10,000 In and Out-of-network
$7,000 In-network
Drugs Covered:Yes

Ready to sign up for Personal Choice 65 Elite Rx (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

Personal Choice 65 Elite Rx (PPO) has a monthly premium of $16.60. 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 $0.00 $16.60 $ $
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

Personal Choice 65 Elite Rx (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
$16.60$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

Personal Choice 65 Elite Rx (PPO) also provides the following benefits.

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

    • In-Network: Yes, contact plan for further details

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 80% Coins – No Copay (Limits Apply)
  • Endodontics
    • In-Network: 20 Coins – No Co pay
    • Out-of-Network: 80% Coins – No Copay
  • Implant Services
    • In-Network: 40 Coins – No Co pay
    • Out-of-Network: 80% Coins – No Copay
  • Oral and Maxillofacial Surgery
    • In-Network: 20-40 Coins – No Co pay (Limits Apply)
    • Out-of-Network: 80% Coins – No Copay (Limits Apply)
  • Periodontics
    • In-Network: 20 Coins – No Co pay
    • Out-of-Network: 80% Coins – No Copay
  • Prosthodontics, fixed
    • In-Network: 40 Coins – No Co pay
    • Out-of-Network: 80% Coins – No Copay
  • Prosthodontics, removable
    • In-Network: 40 Coins – No Co pay
    • Out-of-Network: 80% Coins – No Copay
  • Restorative Services
    • In-Network: 20 Coins – No Co pay
    • Out-of-Network: 80% Coins – No Copay

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 80% Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 80% Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 80% Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 80% Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Lab services
    • In-Network: $0 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0-275 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $35 copay (Authorization Required)

Doctor visits

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

Emergency care/Urgent care

  • Urgent care
    • $5-45 copay per visit (always covered)
  • Emergency
    • $100 copay per visit (always covered)

Foot care (podiatry services)

  • Routine foot care
    • In-Network: $25 copay (Limits Apply)
  • Foot exams and treatment
    • Out-of-Network: 30% coinsurance
    • In-Network: $25 copay

Ground ambulance

    • Out-of-Network: $225 copay
    • In-Network: $225 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • Out-of-Network: $0 copay
  • Hearing aids
    • In-Network: $399-699 copay (Limits Apply)
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • In-Network: $30 copay
    • Out-of-Network: 30% coinsurance
  • Fitting/evaluation
    • In-Network: $0 copay
  • Hearing aids
    • Out-of-Network: $399-699 copay (Limits Apply)

Inpatient hospital coverage

    • Out-of-Network: 30% per stay (Authorization Required)
    • In-Network: $525 per stay
      $0 per day for days 91 and beyond (Authorization Required)

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

    • $10,000 In and Out-of-network
      $7,000 In-network

Medical equipment/supplies

  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item (Authorization Required)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 30% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • Out-of-Network: 30% per stay (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $20 copay (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $30 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: 30% coinsurance
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 30% coinsurance
  • Inpatient hospital – psychiatric
    • In-Network: $525 per stay (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $20 copay
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $30 copay
  • Outpatient individual therapy visit
    • Out-of-Network: 30% coinsurance (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $250 copay per visit (Authorization Required)
    • Out-of-Network: 30% coinsurance per visit (Authorization Required)

Preventive care

    • Out-of-Network: 30% coinsurance (Authorization Required)
    • In-Network: $0 copay (Authorization Required)

Rehabilitation services

  • Occupational therapy visit
    • In-Network: $30 copay
  • Physical therapy and speech and language therapy visit
    • In-Network: $30 copay
    • Out-of-Network: 30% coinsurance
  • Occupational therapy visit
    • Out-of-Network: 30% coinsurance

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)
    • Out-of-Network: 30% per stay (Authorization Required)

Transportation

    • Not covered

Vision

  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Contact lenses
    • Out-of-Network: 80% coinsurance (Limits Apply)
  • Eyeglass frames
    • Not covered
  • Eyeglass lenses
    • Not covered
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Not covered
  • Routine eye exam
    • Out-of-Network: 80% coinsurance (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: 80% coinsurance (Limits Apply)
  • Upgrades
    • Not covered

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

    • Covered

Ready to sign up for Personal Choice 65 Elite Rx (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

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