Personal Choice 2020 - Independence Blue Cross .
Personal Choice 65 PPOSM2020Summary of BenefitsEffective January 1, 2020 through December 31, 2020 Personal Choice 65SM Prime Rx PPO Personal Choice 65SM Medical-Only PPO Personal Choice 65SM Rx PPOH3909Y0041 H3909 PC 20 77038 M Accepted 9/2/2019
This page intentionally left blank.2
This booklet gives you a summary of what we coverand what you pay. It doesn’t list every service that wecover or list every limitation or exclusion. To get acomplete list of services we cover, call us and ask for theEvidence of Coverage or go online at www.ibxmedicare.com.This Summary of Benefits booklet gives you a summary of what Personal Choice 65SMPrime Rx PPO, Personal Choice 65SM Medical-Only PPO, and Personal Choice 65SMRx PPO cover and what you pay.Personal Choice 65SM Prime Rx PPO, Personal Choice 65SM Medical-Only PPO,and Personal Choice 65SM Rx PPO are Medicare Advantage PPO (Preferred ProviderOrganization) plans. With a PPO plan, members don’t have to choose a PCP and cango to doctors in or out of the plan’s network. If members use out-of-network doctors,hospitals, or other health care providers, they will pay more for their services.If you want to compare our plans with other available Medicare health plans,ask the other plan(s) for their Summary of Benefits booklet. Or, use the Medicare PlanFinder at www.medicare.gov.If you want to know more about the coverage and costs of Original Medicare,look in your current “Medicare and You” handbook. View it online atwww.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24hours a day, 7 days a week. TTY users should call 1-877-486-2048.Sections of this booklet M onthly Premium, Deductible, Limits on How Much You Payfor Covered ServicesCovered Medical and Hospital BenefitsP rescription Drug Benefits for Personal Choice 65SM Prime Rx PPOand Personal Choice 65SM Rx PPOO ptional Supplemental Benefits (Choice and Choice Plus Programs)You must pay an extra premium for these benefits.Who can join?To join Personal Choice 65SM Prime Rx PPO, Personal Choice 65SM Medical-Only PPO,and Personal Choice 65SM Rx PPO, you must be entitled to Medicare Part A, be enrolledin Medicare Part B, and live in our service area.The service area for Personal Choice 65SM Medical-Only PPO is Bucks and Philadelphiacounties in Pennsylvania.The service area for Personal Choice 65SM Prime Rx PPO and Personal Choice 65SM RxPPO is Bucks, Chester, Delaware, Montgomery, and Philadelphia countiesin Pennsylvania.3
Which doctors, hospitals, and pharmacies can I use?Personal Choice 65SM Prime Rx PPO, Personal Choice 65SM Medical-Only PPO,and Personal Choice 65SM Rx PPO have a network of doctors, hospitals, pharmacies,and other providers. If you use the providers that are not in our network, a higher costsharing may apply. Personal Choice 65SM Prime Rx PPO and Personal Choice 65 RxPPO have a preferred pharmacy network; cost-sharing for drugs may vary depending onthe pharmacy you use. To view our list of network providers and pharmacies (Provider/Pharmacy Directory),please visit www.ibxmedicare.com.Personal Choice 65SM Prime Rx PPO and Personal Choice 65SM Rx PPO coverPart D drugs. In addition, the plans cover Part B drugs such as chemotherapyand some other drugs administered by your provider. You can see our complete planFormulary (List of Covered Drugs) and any restrictions on our website,www.ibxmedicare.com.Personal Choice 65SM Medical-Only PPO covers Part B drugs, including chemotherapyand some other drugs administered by your provider.However, the plan does not cover Part D prescription drugs.4
Monthly Plan PremiumPersonal Choice 65SM Prime Rx PPOAnd you have If you live in Personal Choice 65SMPrime Rx PPOPersonal Choice 65SMPrime Rx PPO withChoicePersonal Choice 65SMPrime Rx PPO withChoice Plus 12 25 12 25Personal Choice 65SMMedical-Only PPOwith ChoicePersonal Choice 65SMMedical-Only PPOwith Choice Plusn/an/a 196 209Personal Choice 65SMRx PPO with ChoicePersonal Choice 65SMRx PPO with ChoicePlus 171 184 300 313You pay 0Chester, Delaware, orMontgomery CountyBucks or Philadelphia Coun- 0tyPersonal Choice 65SM Medical-Only PPOAnd you have If you live in Personal Choice 65SMMedical-Only PPOYou pay n/aChester, Delaware, orMontgomery CountyBucks or Philadelphia Coun- 184tyPersonal Choice 65SM Rx PPOAnd you have If you live in Personal Choice 65SMRx PPOYou pay 159Chester, Delaware, orMontgomery CountyBucks or Philadelphia Coun- 288ty5
Personal Choice 65SMPrime Rx PPODeductibleThis plan has a 1,000 deductible for covered medical services received from out-of-network providers.Does not apply to preventive services or supplementalbenefits.This plan does not have a deductible for covered PartD drugs.Maximum Out-of-Pocket(the amounts you pay for your premium,Part D prescription drugs and some medicalservices do not count toward your maximumout-of-pocket amount)In-Network: 6,700 each yearOur plan has a yearly coverage limit for certainin-network benefits.Contact us for the services that apply.Combined In-Network and Out-of-Network: 10,000 eachyear6
Personal Choice 65SMMedical-Only PPOPersonal Choice 65SMRx PPOThis plan does not have a deductible for covered medicalThis plan does not have a deductible for coveredservices.medical services or Part D prescription drugs.In-Network: 5,500 each yearIn-Network: 5,500 each yearOur plan has a yearly coverage limit for certainOur plan has a yearly coverage limit for certainin-network benefits.in-network benefits.Contact us for the services that apply.Contact us for the services that apply.Combined In-Network and Out-of-Network: 10,000 eachCombined In-Network and Out-of-Network: 10,000yeareach year7
Covered Medical and Hospital BenefitsPersonal Choice 65SMPrime Rx PPOInpatient Hospital Coverage (1)In-Network: 250 copayment per day, days 1 through7 per admission for Preferred Hospital 310 copayment per day,for days 1 through 7 peradmission for Standard HospitalYou pay nothing per day for days 8 and beyond peradmission. No copayment on day of discharge.Out-of-Network: 30% coinsurance after deductibleOutpatient Hospital Coverage Ambulatory Surgical Center (1)In-Network: 250 copaymentOut-of-Network: 30% coinsurance after deductible Outpatient Hospital Facility (1) Observation ServicesIn-Network: 375 copayment for a Preferred Hospital 475 copayment for a Standard HospitalOut-of-Network: 30% coinsurance after deductibleIn-Network: 375 copayment per stay for aPreferred Hospital 475 copayment for a Standard HospitalOut-of-Network: 30% coinsurance per stayafter deductibleDoctor’s Office Visits Primary Care Physician Specialist8Services with a (1) may require prior authorization.In-Network: 5 copayment for Preferredprimary care physician 20 copayment for Standard primary care physicianOut-of-Network: 30% coinsurance after deductibleIn-Network: 40 copayment for Preferred specialist 50 copayment for Standard specialistOut-of-Network: 30% coinsurance after deductible
Personal Choice 65SMMedical-Only PPOPersonal Choice 65SMRx PPOIn-Network: 250 copayment per day for days 1through 6 per admissionIn-Network: 250 copayment per day for days 1through 6 per admissionYou pay nothing per day for days 7 and beyond peradmission. No copayment on day of discharge.You pay nothing per day for days 7 and beyond peradmission. No copayment on day of discharge. 1,500 maximum copaymentper admission 1,500 maximum copaymentper admissionOut-of-Network: 30% coinsuranceOut-of-Network: 30% coinsuranceIn-Network: 150 copaymentOut-of-Network: 30% coinsuranceIn-Network: 150 copaymentIn-Network: 300 copaymentOut-of-Network: 30% coinsuranceIn-Network: 300 copaymentIn-Network: 300 copayment per stayOut-of-Network: 30% coinsurance per stayIn-Network: 300 copayment per stayOut-of-Network: 30% coinsurance per stayIn-Network: 5 copaymentOut-of-Network: 30% coinsuranceIn-Network: 5 copaymentOut-of-Network: 30% coinsuranceIn-Network: 40 copaymentOut-of-Network: 30% coinsuranceIn-Network: 40 copaymentOut-of-Network: 30% coinsuranceOut-of-Network: 30% coinsuranceOut-of-Network: 30% coinsurance9
Personal Choice 65SMPrime Rx PPOPreventive CareIn-Network: You pay nothingOut-of-Network: 30% coinsurancePlease refer to the Evidence of Coverage for a complete listing of services. If you receive a separateadditional non-preventive evaluation and/or service, acopayment will apply. The copayment amount dependson the provider type or place of service.Emergency Care — covered worldwideWorldwide copayment outside the U.S. does notcount towards the annual MOOPIn-Network: 90 copaymentNot waived if admittedOut-of-Network: 90 copaymentNot waived if admittedUrgently Needed Services —covered worldwideWorldwide copayment outside the U.S. does notcount towards the annual MOOPIn-Network and Out-of-Network: 10 copayment in aretail clinicNot waived if admittedIn-Network and Out-of-Network: 50 copayment inan urgent care centerNot waived if admittedOut-of-Network: 90 copayment per visit outside ofU.S.Not waived if admittedDiagnostic Services (1), Lab and RadiologyServices (1), and X-rays Diagnostic Radiology Services Lab Services Diagnostic Tests and Procedures Outpatient X-rays10Services with a (1) may require prior authorization.In-Network: 45 or 225 copayment dependingon serviceOut-of-Network: 30% coinsurance after deductibleIn-Network: You pay nothingOut-of-Network: 30% coinsurance after deductibleIn-Network: You pay nothingOut-of-Network: 30% coinsurance after deductibleIn-Network: 45 copayment for routineradiology servicesOut-of-Network: 30% coinsurance after deductiblefor routine radiology services
Personal Choice 65SMMedical-Only PPOPersonal Choice 65SMRx PPOIn-Network: You pay nothingOut-of-Network: 30% coinsuranceIn-Network: You pay nothingOut-of-Network: 30% coinsurancePlease refer to the Evidence of Coverage for a complete listing of services. If you receive a separateadditional non-preventive evaluation and/or service, acopayment will apply. The copayment amount dependson the provider type or place of service.Please refer to the Evidence of Coverage for a completelisting of services. If you receive a separate additionalnon-preventive evaluation and/or service, a copaymentwill apply. The copayment amount depends on theprovider type or place of service.In-Network: 90 copaymentNot waived if admittedOut-of-Network: 90 copaymentNot waived if admittedIn-Network: 90 copaymentNot waived if admittedOut-of-Network: 90 copaymentNot waived if admittedIn-Network: 5 copayment in a retail clinicNot waived if admittedIn-Network: 5 copayment in a retail clinicNot waived if admittedOut-of-Network: 5 copayment in a retail clinicNot waived if admittedOut-of-Network: 5 copayment in a retail clinicNot waived if admittedIn-Network: 40 copayment in an urgent care centerNot waived if admittedIn-Network: 40 copayment in an urgent care centerNot waived if admittedOut-of-Network: 40 copayment in an urgentcare centerNot waived if admittedOut-of-Network: 40 copayment in an urgentcare centerNot waived if admittedIn-Network: 90 copayment per visit outside of U.S.Not waived if admittedIn-Network: 90 copayment per visit outside of U.S.Not waived if admittedOut-of-Network: 90 copayment per visit outside ofU.S.Not waived if admittedOut-of-Network: 90 copayment per visit outside of U.S.Not waived if admittedIn-Network: 40 or 175 copayment dependingon serviceOut-of-Network: 30% coinsuranceIn-Network: You pay nothingOut-of-Network: 30% coinsuranceIn-Network: 40 or 175 copayment dependingon serviceOut-of-Network: 30% coinsuranceIn-Network: You pay nothingOut-of-Network: 30% coinsuranceIn-Network: You pay nothingOut-of-Network: 30% coinsuranceIn-Network: You pay nothingOut-of-Network: 30% coinsuranceIn-Network: 40 copayment forroutine radiology servicesOut-of-Network: 30% coinsurance for routine radiology servicesIn-Network: 40 copayment forroutine radiology servicesOut-of-Network: 30% coinsurance for routineradiology servicesServices with a (1) may require prior authorization.11
Personal Choice 65SMPrime Rx PPOHearing Services Hearing ExamIn-Network: 40 copayment for Medicare-coveredhearing exams received from a Preferred specialist 50 copayment for Medicare-covered hearing examsreceived from a Standard specialistOut-of-Network: 30% coinsurance after deductible forMedicare-covered hearing examsAvailable with Choice or Choice Plus:In-Network and Out-of-Network: 10 copayment for Hearing Aidroutine non-Medicare-covered hearing exams once everyyear.Available with Choice: In-Network andOut-of-network: 699 standard digital hearing aid or 999 premium digital hearing aid copayment per year,per ear; 3 hearing aid fitting and evaluations every year;up to 2 hearing aids every year, one hearing aid per ear.Available with Choice Plus: In-Network and Out-ofNetwork: 499 standard digital hearing aid or 799premium digital hearing aid copayment per year, perear; 3 hearing aid fittings per year; up to 2 hearing aidsevery year, one hearing aid per ear.Routine hearing services and aids are covered whenprovided by a TruHearing provider. Routine hearingservices do not count towards annual MOOP.12Services with a (1) may require prior authorization.
Personal Choice 65SMMedical-Only PPOPersonal Choice 65SMRx PPOIn-Network: 40 copayment for Medicare-coveredhearing examsIn-Network: 40 copayment for Medicare-covered hearing examsOut-of-Network: 30% coinsurance for Medicare-covered hearing examsOut-of-Network: 30% coinsurance for Medicare-covered hearing examsAvailable with Choice or Choice Plus:In-Network and Out-of-Network: 10 copaymentfor routine non-Medicare-covered hearing examsonce every year.Available with Choice or Choice Plus: In-Networkand Out-of-Network: 10 copayment for routinenon-Medicare-covered hearing exams once everyyear.Available with Choice: In-Network andOut-of-network: 699 standard digital hearing aidor 999 premium digital hearing aid copayment peryear, per ear; 3 hearing aid fittings per year; up to 2hearing aids every year, one hearing aid per ear.Available with Choice: In-Network and Out-ofNetwork: 699 standard digital hearing aid or 999 premium digital hearing aid copayment peryear, per ear; 3 hearing aid fittings per year; up to2 hearing aids every year, one hearing aid per ear.Available with Choice Plus: In-Network and Out-ofNetwork: 499 standard digital hearing aid or 799premium digital hearing aid copayment per year, perear; 3 hearing aid fittings per year up to 2 hearingaids every year, one hearing aid per ear.Available with Choice Plus: In-Network andOut-of-Network: 499 standard digital hearingaid or 799 premium digital hearing aid copayment per year, per ear; 3 hearing aidfittings per year; up to 2 hearing aids every year,one hearing aid per ear.Routine hearing services and aids are covered whenprovided by a TruHearing provider. Routine hearingservices do not count towards annual MOOP.Routine hearing services and aids are coveredwhen provided by a TruHearing provider.Routine hearing services do not count towardsannual MOOP.13
Personal Choice 65SMPrime Rx PPODental ServicesIn-Network: 40 copayment for non-routine Medicarecovered dental services in a Preferred specialist office; 50 copayment for Medicare-covered dental servicesreceived from a Standard specialistOut-of-Network: 30% coinsurance after deductiblefor non-routine Medicare-covered dental services in aspecialist officeAvailable through Choice: In-Network: 10 copaymentfor routine non-Medicare-covered exam and cleaningevery six months 0 copay for 1 set of dental bite-wing x-rays every year.Full mouth x-rays (panoramic) not covered50% coinsurance for restorative services, endodontics,periodontics, and extractionsOut-of-Network: 80% coinsurance for routine nonMedicare-covered dental services80% coinsurance for restorative services, endodontics,periodontics, and extractions 500 combined plan allowance every year forrestorative dental services, endodontics, periodontics,and extractions.Prosthodontics and oral surgery are not coveredAvailable through Choice Plus: In-Network: 0 copayment for routine non-Medicare-covered examand cleaning every six months 0 copay for 1 set of dental bite-wing x-rays every year.Full mouth x-rays (panoramic) not covered50% coinsurance for restorative services, endodontics,periodontics, extractions, prosthodontics, and oralsurgery 1500 combined in- and out-of-network plan allowanceevery year for restorative services, endodontics,periodontics, extractions, prosthodontics, and oralsurgeryOut-of-Network: 80% coinsurance for routine nonMedicare-covered dental services80% coinsurance for restorative services, endodontics,periodontics, extractions, prosthodontics, and oralsurgery14
Personal Choice 65SMMedical-Only PPOPersonal Choice 65SMRx PPOIn-Network: 40 copayment for non-routine Medicare-covered dental services in a specialist officeOut-of-Network: 30% coinsurance for non-routineMedicare-covered dental services in a specialist officeAvailable through Choice: In-Network: 10 copayment for routine non-Medicare-covered exam andcleaning every six months 0 copayment for 1 set of dental bite-wing x-rays every year. Full mouth x-rays (panoramic) not covered50% coinsurance for restorative services, endodontics, periodontics, and extractionsOut-of-Network: 80% coinsurance for routinenon-Medicare-covered dental services and dentalX-rays80% coinsurance for restorative services, endodontics, periodontics, and extractions 500 combined plan allowance every year for restorative dental services, endodontics, periodontics,and extractions.Prosthodontics and oral surgery are not coveredAvailable through Choice Plus: In-Network: 0copayment for routine non-Medicare-covered examand cleaning every six months 0 copay for 1 set of dental bite-wing x-rays everyyear. Full mouth x-rays (panoramic) not covered50% coinsurance for restorative services, endodontics, periodontics, extractions, prosthodontics, andoral surgeryOut-of-Network: 80% coinsurance for routinenon-Medicare-covered dental services 1500 combined in- and out-of-network plan allowance every year for restorative services, endodontics,periodontics, extractions, prosthodontics, and oralsurgery80% coinsurance for restorative services, endodontics, periodontics, extractions, prosthodontics, andoral surgeryIn-Network: 40 copayment for non-routineMedicare-covered dental services in a specialistofficeOut-of-Network: 30% coinsurance for non-routine Medicare-covered dental services in a specialist officeAvailable through Choice: In-Network: 10 copayment for routine non-Medicare-covered examand cleaning every six months 0 copayment for 1 set of dental bite-wing x-rays every year. Full mouth x-rays (panoramic) not covered50% coinsurance for restorative services, endodontics, periodontics, and extractionsOut-of-Network: 80% coinsurance for routinenon-Medicare-covered dental services and dentalX-rays80% coinsurance for restorative services, endodontics, periodontics, and extractions 500 combined plan allowance every year forrestorative dental services, endodontics, periodontics, and extractions.Prosthodontics and oral surgery are not coveredAvailable through Choice Plus: In-Network: 0 copayment for routine non-Medicare-coveredexam and cleaning every six months 0 copay for 1 set of dental bite-wing x-raysevery year. Full mouth x-rays (panoramic) notcovered50% coinsurance for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgeryOut-of-Network: 80% coinsurance for routinenon-Medicare-covered dental services 1500 combined in- and out-of-network planallowance every year for restorative services,endodontics, periodontics, extractions, prosthodontics, and oral surgery80% coinsurance for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgery15
Personal Choice 65SMPrime Rx PPOVision ServicesIn-Network: 40 copayment for Medicare-coveredeye exams received from a Preferred specialist, 50copayment for Medicare-covered eye exams receivedfrom a Standard specialist; 0 copayment for diabeticretinal eye exam and 0 copayment for Medicarecovered glaucoma screening; 0 copayment for one pairof Medicare-covered eyeglasses or contact lenses aftercataract surgeryOut-of-Network: 30% coinsurance after deductible forMedicare-covered eye exams, diabetic retinal exam,glaucoma screening and for one pair of eyeglasses orcontact lenses after cataract surgeryAvailable through Choice or Choice Plus: 10 copayment for routine eye exam every year; 1 pairof eyeglass frames and lenses or one pair of contactlenses are covered in full every year if purchased fromthe Davis Vision Collection; 150 combined in- and out-of-network plan allowanceevery year for all other eyewear(glasses, lenses or contacts) purchased at aDavis Vision provider. 200 combined in- and out-of-network allowance everyyear for eyewear (glasses and lenses) purchased fromVisionworks.Routine vision services do not count towards the annualMOOP.Out-of-Network: 80% coinsurance16Services with a (1) may require prior authorization.
Personal Choice 65SMMedical-Only PPOPersonal Choice 65SMRx PPOIn-Network: 40 copayment for Medicare-covered eyeIn-Network: 40 copayment for Medicare-covered eyeexams; 0 copayment for diabetic retinal eye exam andexams; 0 copayment for diabetic retinal eye exam and 0 0 copayment for Medicare-covered glaucoma screening;copayment for Medicare-covered glaucoma screening; 0 0 copayment for one pair of Medicare-coveredcopayment for one pair of Medicare-covered eyeglasses oreyeglasses or contact lenses after cataract surgerycontact lenses after cataract surgeryOut-of-Network: 30% coinsurance for Medicare-coveredOut-of-Network: 30% coinsurance for Medicare-coveredeye exams, diabetic retinal exam, glaucoma screening andeye exams, diabetic retinal exam, glaucoma screeningfor one pair of eyeglasses or contact lenses after cataractand for one pair of eyeglasses or contact lenses aftersurgerycataract surgeryAvailable through Choice or Choice Plus:Available through Choice or Choice Plus: 10 copayment for routine eye exam every year; 1 pair 10 copayment for routine eye exam every year;of eyeglass frames and lenses or one pair of contact1 pair of eyeglass frames and lenses or one pairlenses are covered in full every year if purchased fromof contact lenses are covered in full every yearthe Davis Vision Collection;if purchased from the Davis Vision Collection; 150 combined in- and out-of-network plan allowance 150 combined in- and out-of-network plan allowanceevery year for all other eyewearevery year for all other eyewear(glasses, lenses or contacts) purchased at a(glasses, lenses or contacts) purchased at aDavis Vision provider.Davis Vision provider. 200 combined in- and out-of-network plan allowance 200 combined in- and out-of-network plan allowanceevery year for eyewear (glasses and lenses) purchasedevery year for eyewear (glasses and lenses) purchasedfrom Visionworks.from Visionworks.Routine vision services do not count towards the annualRoutine vision services do not count towards theMOOP.annual MOOP.Out-of-Network: 80% coinsuranceOut-of-Network: 80% coinsurance17
Personal Choice 65SMPrime Rx PPOMental Health Services Inpatient Mental Health Care (2)In-Network: 250 copayment per day for PreferredHospital for days 1 through 5 per admission 310 copayment per day for Standard Hospital for days 1through 5 per admissionYou pay nothing per day for days 6 and beyondOut-of-Network: 30% coinsurance after deductible190-day lifetime maximum in a mental health facility Outpatient Therapy(Group and Individual) Outpatient Substance Abuse Services(Group and Individual) Partial Hospitalization (2)In-Network: 40 copayment per therapy sessionOut-of-Network: 30% coinsurance after deductibleIn-Network: 40 copayment per therapy sessionOut-of-Network: 30% coinsurance after deductibleIn-Network: 40 copayment per visitOut-of-Network: 30% coinsurance after deductibleSkilled Nursing Facility (1)In-Network: You pay nothing per day for days 1through 20 165 copayment per day for days 21 through 100per admissionOut-of-Network: 30% coinsurance after deductibleper day for days 1 through 100100 days per benefit periodPhysical TherapyIn-Network: 30 copayment per visitOut-of-Network: 30% coinsurance per visitafter deductibleAmbulance (1) 300 copayment for a one-way tripNot waived if admittedNon-emergency ambulance services require priorauthorizationTransportation18Not coveredServices with a (1) may require prior authorization.(2) Prior authorization is required by Magellan Behavioral Health.
Personal Choice 65SMMedical-Only PPOPersonal Choice 65SMRx PPOIn-Network: 250 copayment per day for daysIn-Network: 250 copayment per day for days 11 through 6 per admission.through 6 per admission.You pay nothing per day for days 7 and beyondOut-of-Network: 30% coinsurance 1,500 maximum copayment per admission190-day lifetime maximum in a mental health facilityYou pay nothing per day for days 7 and beyondOut-of-Network: 30% coinsurance 1,500 maximum copayment per admission190-day lifetime maximum in a mental health facilityIn-Network: 40 copayment per therapy sessionIn-Network: 40 copayment per therapy sessionOut-of-Network: 30% coinsuranceOut-of-Network: 30% coinsuranceIn-Network: 40 copayment per therapy sessionIn-Network: 40 copayment per therapy sessionOut-of-Network: 30% coinsuranceOut-of-Network: 30% coinsuranceIn-Network: 40 copayment per visitIn-Network: 40 copayment per visitOut-of-Network: 30% coinsuranceOut-of-Network: 30% coinsuranceIn-Network: You pay nothing per day for days 1through 20 165 copayment per day for days 21 through 100per admissionOut-of-Network: 30% coinsurance per day for days1 through 100100 days per benefit periodIn-Network: You pay nothing per day for days 1through 20 165 copayment per day for days 21 through 100per admissionOut-of-Network: 30% coinsurance per day for days1 through 100100 days per benefit periodIn-Network: 20 copayment per visitOut-of-Network: 30% coinsurance per visitIn-Network: 20 copayment per visitOut-of-Network: 30% coinsurance per visit 175 copayment for a one-way tripNot waived if admitted 175 copayment for a one-way tripNot waived if admittedNon-emergency ambulance services require priorauthorizationNon-emergency ambulance services require priorauthorizationNot coveredNot covered19
Personal Choice 65SMPrime Rx PPOMedicare Part B Drugs (1)In-Network: 20% coinsurance for Part B drugs such aschemotherapy drugsOut-of-Network: 30% coinsurance for Part B drugs suchas chemotherapy drugsFor a description of the types of drugs available underPart B, see your Evidence of CoveragePrescription Drug Benefits (Part D)Part D Prescription Drug Benefits are available for members of Personal Choice 65 Rx PPO and Personal Choice 65Prime Rx PPO. This benefit is not available for members of Personal Choice 65SM Medical-Only PPO.Personal Choice 65SMPrime Rx PPOInitial Coverage StageYou pay the following until your total yearly drug costsreach 4,020. “Total yearly drug costs” are the total drugcosts paid by both you and our Part D plan.You may get your drugs at network retail pharmacies andmail-order pharmacies.Cost-sharing may change depending on the pharmacyyou choose and when you move into each stage of yourPart D benefits. You may fill your prescriptions ateither a preferred or standard pharmacy. Tier 1 and 2prescriptions (which include most generic drugs) will havelower copayments when you have them filled at preferredpharmacies. For information, please review the PersonalChoice 65SM Prime Rx PPO Evidence of Coverage.20Services with a (1) may require prior authorization.
Personal Choice 65SMMedical-Only PPOPersonal Choice 65SMRx PPOIn-Network: 20% coinsurance for Part B drugs such asIn-Network: 20% coinsurance for Part B drugs suchchemotherapy drugsas chemotherapy drugsOut-of-Network: 30% coinsurance for Part B drugs suchOut-of-Network: 30% coinsurance for Part B drugsas chemotherapy drugssuch as chemotherapy drugsFor a description of the types of drugs available underFor a description of the types of drugs available underPart B, see your Evidence of CoveragePart B, see your Evidence of CoveragePersonal Choice 65SMMedical-Only PPOPart D prescription drugs are not available with thisplan.Personal Choice 65SMRx PPOYou pay the following until your total yearly drug costsreach 4,020. “Total yearly drug costs” are the totaldrug costs paid by both you and our Part D plan.You may get your drugs at network retail pharmaciesand mail-order pharmacies.Cost-sharing may change depending on the pharmacyyou choose and when you move intoeach stage of your Part D benefits. You may fillyour prescriptions at either a preferred orstandard pharmacy. Tier 1 and 2 prescriptions (whichinclude most generic drugs) will have lower copaymentswhen you have them filled at preferred pharmacies. Forinformation, please review the Personal Choice 65SMRx PPO Evidence of Coverage.21
Personal Choice 65SMPrime Rx PPORetail Cost-sharing(what you pay at a pharmacy SupplyPreferred Pharmacy 2 copayment 4 copayment 4 copaymentStandard Pharmacy 9 copayment 18 copayment 27 copaymentPreferred Pharmacy 10 copayment 20 copayment 20 copaymentStandard Pharmacy 20 copayment 40 copayment 60 copaymentPreferred Pharmacy 47 copayment 94 copayment 141 copaymentStandard Pharmacy 47 copayment 94 copayment 141 copaymentPreferred Pharmacy 100 copayment 200 copayment 300 copaymentStandard Pharmacy 100 copayment 200 copayment 300 copaymentPreferred Pharmacy33% coinsurance33% coinsurance33% coinsuranceStandard Pharmacy33% coinsurance33% coinsurance33% thSupplyTier 1 (Preferred Generic Drugs)Tier 2 (Generic Drugs)Tier 3 (Preferred Brand Drugs)Tier 4 (Non-Preferred Drugs)Tier 5 (Specialty Drugs)Mail-Ord
Optional Supplemental Benefits (Choice and Choice Plus Programs) You must pay an extra premium for these benefits. Who can join? To join Personal Choice 65 SM Prime Rx PPO, Personal Choice 65 Medical-Only PPO, and Personal Choice 65SM Rx PPO, you must be entitled to Medicare Part A, be e
Blue Shield 65 Plus Choice Plan (HMO) X Blue Shield of California Blue Shield Inspire (HMO) X Blue Shield of California Blue Shield Medicare (PPO) Blue Shield Promise X Blue Shield of California AdvantageOptimum Plan (HMO) Blue Shield Promise X Blue Shield of California AdvantageOpt
Blue Cross and Blue Shield of Alabama is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield Association permits us to use the Blue Cross and Blue Shield service marks in the state of Alabama.
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross Blue Shield Association. Florida Blue January 2021 Open Medication Guide IV
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross Blue Shield Association Florida Blue November 2022 Care Choices Medication Guide (for HSA Plans)
4 blue brute /big blue /ultra blue installation guide the physical (or chemical) properties of jm eagle blue brute pvc c.i.o.d. distribution pipe (awwa c900) ,big blue pvc c.i.o.d. transmission pipe (awwa c905), ultra blue pvco c.i.o.d. distribution pipe (awwa c909), and ultra blue pvco i.p.s. distribution pipe (astm f1483) presented in this booklet,
Blue Essentials, Blue Advantage HMO and Blue Premier claims must be submitted within 180 days of the date of service. Blue Essentials, Blue Advantage HMO and Blue Premier physicians, professional providers, facility and ancillary providers must submit a complete claim for any services provided to a member. Claims that are
16C37 Reef Green 16D45 Dark Jade 16E53 Aquamarine 18B17 Blue Mink 18B21 Squirrel Grey 18B25 Dark Admiralty Grey 18B29 Raven 18C31 Ice Blue. 18C35 Corvette Blue 18C39 Fathom Blue 18D43 Dresden Blue 18E49 Crystal Blue 18E50 Ribbon Blue 18E51 Delphinium Blue 18E53 Tartan Blue 20C33 Porcel
Superior Court of California County of Imperial “NOTICE OF UNCLAIMED MONIES” I, Maria Rhinehart, Court Executive Officer, Superior Court of California, County of
