2017 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Platinum Blue Choice Plan with Rx (Cost) | ||||
Location: | Mahnomen, Minnesota Click to see other locations | ||||
Plan ID: | H2461 - 009 - 0 Click to see other plans | ||||
Member Services: | 1-866-340-8654 TTY users 711 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Platinum Blue Choice Plan with Rx (Cost) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $110.70 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $400 (Tier 1, 2 and 6 excluded from the Deductible.) | ||||
Annual Rx Initial Coverage Limit (ICL): | $3,700 | ||||
Health Plan Type: | Cost | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,000 | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,351 drugs | Browse the Platinum Blue Choice Plan with Rx (Cost) Formulary | |||
This plan has 6 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $6.00 | $12.00 | 20% | 45% | 25% |
• Number of Drugs per Tier: | 243 | 1538 | 262 | 528 | 615 |
Plan's Pharmacy Search: | http://www.primetherapeutics.com | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Minnesota: | 12,441 members | ||||
Number of Members enrolled in this plan in (H2461 - 009): | 23,749 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | 4 out of 5 Stars. | ||||
• Member Experience Rating: | Insufficient data to rate this plan. | ||||
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** General Plan Information ** | |||||
Choice of Doctors?: Plan Doctors for Most Services | |||||
** Cost ** | |||||
Monthly Health Plan Premium: $74.00 | |||||
Monthly Drug Plan Premium: $36.70 | |||||
Health Plan Deductible: $0 | |||||
Other Health Plan Deductibles?: No | |||||
Maximum Out-of-Pocket Enrollee Responsibility (does not include prescription drugs) : $3,000 In-network | |||||
** Extra Benefits ** | |||||
Prescription Drugs Covered?: Yes | |||||
Optional Supplemental Benefits?: No | |||||
** Outpatient Care and Services ** | |||||
Ambulance: $25 | |||||
Doctor's office visits:
| |||||
Durable medical equipment (wheelchairs, oxygen, etc.): 20% per item | |||||
Emergency care: $50 per visit (always covered) | |||||
Home health care: You pay nothing | |||||
Mental health care: $100 per stay | |||||
Outpatient hospital: $0-50 per visit | |||||
Renal dialysis: $15 per visit | |||||
** Inpatient Care ** | |||||
Inpatient hospital care: $100 per stay | |||||
Optional Supplemental Benefits?: No | |||||
Skilled Nursing Facility (SNF): You pay nothing | |||||
Prescription Drugs Covered?: Yes | |||||
** Additional Benefits ** | |||||
Optional Supplemental Benefits?: No |