Personal Choice 65 Achieve Rx (PPO) Medicare Advantage Plan H3909-020 • 2027
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- Coming soon
- Maximum Out-of-Pocket
- $9850.00In-network
- Part B Giveback
- Coming soon
- Prescription Coverage
- Enhanced, $700.00 deductible
- Additional Benefits
- None
- Service Area
- See List
- Total Enrollment
- 13,461 beneficiaries
Personal Choice 65 Achieve Rx (PPO) Introduction
This Medicare Advantage PPO plan, Personal Choice 65 Achieve Rx, is offered by Independence Blue Cross and uses a Preferred Provider Organization (PPO) provider network. It comes with prescription drug coverage. For the 2027 plan year, the monthly premium is $0.00, the medical deductible is Coming soon, and the in-network maximum out-of-pocket is $9850.00. The plan is identified by CMS Plan ID H3909-020. The 2027 Part D prescription drug deductible is $700.00.
Plan Benefits
Personal Choice 65 Achieve Rx includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The tables below outline the most common in-network out-of-pocket costs associated with plan H3909-020.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | Coming soon | In-network: $0 copay Out-of-network: 50% coinsurance |
| Specialist | Coming soon | In-network: $55 copay Out-of-network: 50% coinsurance |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | Coming soon | In-network: $0 copay |
| Telehealth benefit | Coming soon | In-network: $0-$55 copay |
| Routine chiropractic | Coming soon | In-network: $15 copay Out-of-network: 50% coinsurance |
| Fitness benefits | Coming soon | In-network: $0 copay Out-of-network: $0 copay |
| Health education | Coming soon | In-network: $0 copay Out-of-network: $0 copay |
| Counseling services | Coming soon | Not covered |
| Over-the-counter drug benefits | Coming soon | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Health transportation (non-emergency) | Coming soon | Not covered |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | Coming soon | In-network: $0-$500 copay Out-of-network: 50% coinsurance |
| Lab services | Coming soon | In-network: $0 copay Out-of-network: 50% coinsurance |
| Outpatient x-rays | Coming soon | In-network: $40 copay Out-of-network: 50% coinsurance |
| Diagnostic tests and procedures | Coming soon | In-network: $0 copay Out-of-network: 50% coinsurance |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | Coming soon | $130 copay |
| Worldwide emergency care | Coming soon | $130 copay |
| Urgent care | Coming soon | $10-$50 copay |
| Inpatient hospital care | Coming soon | In-network: Tier 1 $390 per day for days 1-7 $0 per day for days 8-90 $0 per stay Out-of-network: 50% per stay |
| Skilled Nursing Facility | Coming soon | In-network: Tier 1 $0 per day for days 1-20 $218 per day for days 21-100 Out-of-network: 50% per stay |
| Ground ambulance | Coming soon | In-network: $310 copay Out-of-network: $310 copay |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | Coming soon | In-network: $30 copay Out-of-network: 50% coinsurance |
| Outpatient group therapy | Coming soon | In-network: $20 copay Out-of-network: 50% coinsurance |
| Inpatient psychiatric hospital care | Coming soon | In-network: Tier 1 $390 per day for days 1-7 $0 per day for days 8-90 $0 per stay Out-of-network: 50% per stay |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | Coming soon | In-network: $50 copay Out-of-network: 50% coinsurance |
| Occupational therapy | Coming soon | In-network: $50 copay Out-of-network: 50% coinsurance |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | Coming soon | In-network: 0%-20% coinsurance Out-of-network: 50% coinsurance |
| Durable medical equipment | Coming soon | In-network: 20% coinsurance Out-of-network: 50% coinsurance |
| Prosthetics | Coming soon | In-network: 20% coinsurance Out-of-network: 50% coinsurance |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | Coming soon | In-network: 0%-20% coinsurance Out-of-network: 50% coinsurance |
| Other Part B drugs (Medicare-covered) | Coming soon | In-network: 0%-20% coinsurance Out-of-network: 50% coinsurance |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | Coming soon | In-network: $0 copay Out-of-network: 80% coinsurance |
| Dental x-rays | Coming soon | In-network: $0 copay Out-of-network: 80% coinsurance |
| Cleaning | Coming soon | In-network: $0 copay Out-of-network: 80% coinsurance |
| Periodontics | Coming soon | In-network: 50% coinsurance Out-of-network: 80% coinsurance |
| Endodontics | Coming soon | In-network: 50% coinsurance Out-of-network: 80% coinsurance |
| Restorative services | Coming soon | In-network: 50% coinsurance Out-of-network: 80% coinsurance |
| Implant services | Coming soon | In-network: 50% coinsurance Out-of-network: 80% coinsurance |
| Orthodontics | Coming soon | Not covered |
| Oral/Maxillofacial surgery | Coming soon | In-network: 50% coinsurance Out-of-network: 80% coinsurance |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | Coming soon | In-network: $0 copay Out-of-network: 80% coinsurance |
| Contact lenses | Coming soon | In-network: $0 copay Out-of-network: 80% coinsurance |
| Eyeglass frames only | Coming soon | Not covered |
| Eyeglass lenses only | Coming soon | Not covered |
| Eyeglasses (frames & lenses) | Coming soon | In-network: $0 copay Out-of-network: 80% coinsurance |
| Upgrades | Coming soon | Not covered |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | Coming soon | In-network: $0 copay Out-of-network: $0 copay |
| Fitting/evaluation | Coming soon | In-network: $0 copay Out-of-network: $0 copay |
| Prescription hearing aids | Coming soon | In-network: $699-$999 copay Out-of-network: $699-$999 copay |
| OTC hearing aids | Coming soon | Not covered |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Coming soon | Not covered |
| Home-based palliative care | Coming soon | In-network: $0 copay Out-of-network: $0 copay |
| Personal emergency response system | Coming soon | Not covered |
| Weight management programs | Coming soon | Not covered |
| Wigs for chemotherapy-related hair loss | Coming soon | Not covered |
| Alternative therapies | Coming soon | Not covered |
| Massage therapy | Coming soon | Not covered |
| Home/bathroom safety devices | Coming soon | Not covered |
Certain preventive services are covered 100% by Personal Choice 65 Achieve Rx as a Part B benefit.
Prescription Drug Coverage
Personal Choice 65 Achieve Rx includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $0.00 |
| Supplemental Part D Premium: | $$0.00 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $12.80 |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $700.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Independence Blue Cross starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, Personal Choice 65 Achieve Rx may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Cost data not available. | ||
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H3909)
CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Contact Information for Independence Blue Cross
- Website
- Independence Blue Cross Plan Page
- Providers
- Independence Blue Cross Providers Page
- Formulary
- Independence Blue Cross Formulary Page
- Pharmacy
- Independence Blue Cross Pharmacy Page
- New Member Health Plan Help
- (877)393-6733
- New Member Health Plan TTY
- 711
- New Member Part D Help
- (877)393-6733
- New Member Part D TTY Users
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Plan Availability
Personal Choice 65 Achieve Rx (H3909-020-0) is available in the following locations:
Pennsylvania Counties Served
Frequently Asked Questions
Here are some of the most frequently asked questions about this plan (click to open).
Frequently Asked Questions About Personal Choice 65 Achieve Rx (PPO)
Is there a monthly premium for this plan in 2027?
For 2027, the monthly premium is $0.00. Medicare Part B premiums apply in addition to this amount.
What is the in-network MOOP for plan H3909-020?
For 2027, the in-network maximum out-of-pocket is $9850.00. The plan pays 100% of covered in-network services beyond this amount.
What is the CMS star rating for this plan?
CMS rates this plan at ★4.0 out of 5 stars for 2027.
What is the total enrollment for plan H3909-020?
Total enrollment is 13,461 beneficiaries based on the latest CMS data.
Is there a Part D deductible for this plan?
The Part D deductible is $700.00.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | November 10, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | November 10, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | November 10, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | November 10, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Independence Blue Cross (official source) | http://www.ibxmedicare.com | October 4, 2026 |
| CMS.gov | Medicare Advantage Plan Fact Sheet | 25 May, 2025 |
| Medicare.gov | Joining a plan | 25 May, 2025 |
| Medicare.gov | Your coverage options | 25 May, 2025 |
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Provenance documentation for this data is maintained under the U.S. Core Data for Interoperability (USCDI) Provenance standard.
Page content independently curated and maintained by David W. Bynon, Editorial Steward, using a standardized, data-driven methodology for accurate, non-commercial Medicare plan interpretation and resolution.