4

4 out of 5 stars* for plan year 2024

Plan ID: H3909-001

What You Need to Know:

  • Personal Choice 65 Rx (PPO) is a Medicare Advantage Health Maintenance Organization Local PPO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $290, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is .
  • The plan includes an out-of-pocket maximum of $5,000 per year (in-network).
  • Personal Choice 65 Rx (PPO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is .
  • This plan's Part D Initial Coverage Limit is $77.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$290

Monthly Premium

Medicare Plan Features
Monthly Premium: $290.00
Part C Premium: $192.3
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$290.00 $192.3 $76.80 $20.90 $97.70 $0 0.0
Gap Coverage: No
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local PPO
Similar Plan: H3909-007
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: No additional gap coverage, only the Donut Hole Discount
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $5,000
Annual Deductible: NULL
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Philadelphia, Pennsylvania: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
952 members 3.5 out of 5 Stars. 4 out of 5 Stars. 4 out of 5 Stars.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 4,338 drugs
Number of Members Enrolled in this Plan in Philadelphia, Pennsylvania: 1,768 members
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$192.30 $76.80 $20.90 $290.00
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$252.50 $88.30 $280.60 $79.00 $271.30 $69.60 $261.90
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
358 $1.00 1838 $9.00 421 $47.00 635 $100.00 1086 33%

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Aetna Medicare Advantra Premier Plus (PPO) (2023)Local PPO$7,000$0
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Aetna Medicare Advantra Value (HMO) (2023)Local HMO$7,550$0
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5
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4
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4
Cigna Preferred Plus Medicare (HMO) (2023)Local HMO$5,100$0
4
Cigna Fundamental Medicare (HMO) (2023)Local HMO *$6,900$-
4
Cigna Preferred Medicare (HMO) (2023)Local HMO$5,900$0
4
Cigna Alliance Medicare (HMO) (2023)Local HMO$6,900$0
4
HumanaChoice H5216-116 (PPO) (2023)Local PPO *$3,900$-
4
Keystone 65 Preferred Rx (HMO) (2023)Local HMO$4,000$0
3
Keystone 65 Preferred Medical Only (HMO) (2023)Local HMO *$4,000$-
3
Keystone 65 Select Rx (HMO) (2023)Local HMO$4,900$0
3
Keystone 65 Select Medical Only (HMO) (2023)Local HMO *$4,900$-
3
Keystone 65 Focus Rx (HMO-POS) (2023)Local HMO$6,500$0
3
Keystone 65 Basic Rx (HMO) (2023)Local HMO$7,550$0
3
Aetna Medicare Advantra Premier (HMO) (2023)Local HMO$7,550$150
5
Personal Choice 65 Prime Rx (PPO) (2023)Local PPO$7,550$0
4
AARP Medicare Advantage Patriot (HMO) (2023)Local HMO *$5,500$-
5
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4
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5
AARP Medicare Advantage Choice Plan 2 (PPO) (2023)Local PPO$6,700$0
5
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4
Allwell Medicare Boost (HMO) (2023)Local HMO$7,550$0
4
Allwell Medicare (HMO) (2023)Local HMO$6,700$0
4
Aetna Medicare Premier Plus (HMO) (2023)Local HMO$7,550$0
5
Aetna Medicare Premier (HMO) (2023)Local HMO$7,550$0
5
Lasso Healthcare Growth Plus (MSA) (2023)MSA *$-$-
4
AARP Medicare Advantage (HMO) (2023)Local HMO$6,700$200
5
Aetna Medicare Silver (HMO) (2023)Local HMO$7,550$0
5
Allwell Medicare Complement (HMO) (2023)Local HMO$7,550$445
4
Personal Choice 65 Medical Only (PPO) (2023)Local PPO *$5,000$-
4
Medicare Advantage Plans by Independence Blue Cross
Keystone 65 Preferred Rx (HMO) (2023)Local HMO$4,000$0
3
Keystone 65 Preferred Medical Only (HMO) (2023)Local HMO *$4,000$-
3
Keystone 65 Select Rx (HMO) (2023)Local HMO$4,900$0
3
Keystone 65 Select Medical Only (HMO) (2023)Local HMO *$4,900$-
3
Keystone 65 Focus Rx (HMO-POS) (2023)Local HMO$6,500$0
3
Keystone 65 Basic Rx (HMO) (2023)Local HMO$7,550$0
3
Personal Choice 65 Prime Rx (PPO) (2023)Local PPO$7,550$0
4
Personal Choice 65 Medical Only (PPO) (2023)Local PPO *$5,000$-
4

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