How the Plan Works

Personal Choice 65^SM PPO

Personal Choice 65 PPO, a Preferred Provider Organization combines the savings and convenience of a large, local health care network, without referrals, plus coverage anywhere in the U.S. Add prescription drug coverage, and pay less for your Medicare Part D prescription drugs.

With Personal Choice 65 PPO, there is no need to select a primary care physician and you don’t need to get a referral to see a specialist. Most health care services can be obtained by simply showing your Personal Choice 65 PPO ID card. There are virtually no claim forms for in-network care, and no supplemental coverage to coordinate.

Personal Choice 65 PPO has formed a network of more than 22,000 area physicians and specialists. You are free to use any provider who is part of our network. You may also go to providers outside of our network, but your out-of-pocket costs may be higher.

While referrals are not required, we recommend that you confirm that services are covered and medically necessary for certain out-of-network services.

Monthly premiums

	Personal Choice 65 PPO
Medical-Only Plan	$225 monthly premium No Part D coverage
Medical plus prescription drug	$261.20 monthly premium

There is no deductible for either plan option, unless you use services outside of the network, and higher cost-sharing may apply.

Prescription Coverage

You may select a plan with or without prescription coverage. 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. Check the Drug Formulary for a complete listing of covered drugs.

The Personal Choice 65 Rx PPO Plan includes Medicare Part D prescription drug coverage. You can go to thousands of pharmacies within the network and simply present your Personal Choice 65 PPO card. However, covered Part D drugs are available 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 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	$275 yearly deductible
Copay	After you pay the yearly deductible you will pay: $3 for generics $30 for preferred brand $65 for non-preferred brand 25% Specialty
Gap coverage	Once your total yearly drug costs reach $2,830, you pay 100% at discounted prices
Maximum out-of-pocket costs	After you reach $4,550, you pay the greater of either: $2.50 for generic drugs or $6.30 for all other drugs or 5% of you drug costs

Summary of Benefits

For details of covered services, copays, and deductibles for the Personal Choice 65 PPO plan, see the Summary of Benefits.

Need extra help with health plan and drug costs?

If you have limited income and resources, you may qualify for low-income subsidy. When you join Personal Choice 65 PPO, Medicare will tell us how much extra help you are getting. Then we will let you know the amount you will pay. If you qualify, your drug costs will also be lower.

You can see if you qualify for a low-income subsidy by calling:

1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048), 24 hours a day/7 days a week
Pennsylvania Office of Medical Assistance Programs (Medicaid) at 1-717-787-1870
The Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778), 7 a.m. to 7 p.m., Monday through Friday

Important Note:
If you’re interested in this drug benefit, you must choose Personal Choice 65 Rx PPO. You cannot get a stand-alone Part D prescription drug plan if you opt for Personal Choice 65 Medical-Only PPO. If you’re interested in a Medicare supplement with a stand-alone prescription drug option, see Security 65^®.

To obtain more information, please call 1-877-393-6733 (TTY/TDD: 1-877-219-5457), 8 a.m. to 8 p.m., seven days a week.