2018 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Platinum Blue Choice Plan with Rx (Cost) | ||||
Location: | Beltrami, 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: | $108.30 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $405 (Tier 1 and 6 excluded from the Deductible.) | ||||
Annual Rx Initial Coverage Limit (ICL): | $3,750 | ||||
Health Plan Type: | Cost | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $4,000 | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,474 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: | $5.00 | $10.00 | 20% | 45% | 25% |
• Number of Drugs per Tier: | 239 | 1279 | 458 | 591 | 736 |
Plan's Pharmacy Search: | http://www.myprime.com | ||||
Plan Offers Mail Order? | No | ||||
Number of Members enrolled in this plan in Beltrami, Minnesota: | 336 members | ||||
Number of Members enrolled in this plan in Minnesota: | 14,308 members | ||||
Number of Members enrolled in this plan in (H2461 - 009): | 30,733 members | ||||
Plan’s Summary Star Rating: | 5 out of 5 Stars. This plan qualifies for the 5-star rating Special Enrollment period. Read more. | ||||
• Customer Service Rating: | 5 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 — | |||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Basic Premium | Part D Supplemental Premium | |
$108.30 | $0.00 | $32.10 | $2.20 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $2.20 | $10.20 | $18.20 | $26.30 | |
Total Monthly Premium with LIS (Parts C & D): | $2.20 | $10.20 | $18.20 | $26.30 |
— Plan Health Benefits — | |||||
** Benefit Highlights ** | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $4,000 In-network | |||||
Optional supplemental benefits | |||||
• No | |||||
Inpatient hospital coverage | |||||
• $200 per stay | |||||
Outpatient hospital coverage | |||||
• $0-50 per visit | |||||
Preventive care | |||||
• $0 copay | |||||
Health plan deductible | |||||
• $0 | |||||
Other health plan deductibles? | |||||
• In-Network: No | |||||
Doctor visits | |||||
• Primary: $5 per visit | |||||
• Specialist: $15 per visit | |||||
Emergency care/Urgent care | |||||
• Emergency: $80 per visit (always covered) | |||||
• Urgent care: $25 per visit (always covered) | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: $0 copay | |||||
• Lab services: $0 copay | |||||
• Diagnostic radiology services (e.g., MRI): $0 copay | |||||
• Outpatient x-rays: $0 copay | |||||
Mental health services | |||||
• $200 per stay | |||||
Skilled Nursing Facility | |||||
• $0 copay | |||||
Ambulance | |||||
• $25 | |||||
Transportation | |||||
• Not covered | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Mental health services | |||||
• Outpatient group therapy visit with a psychiatrist: $15 | |||||
• Outpatient individual therapy visit with a psychiatrist: $15 | |||||
• Outpatient group therapy visit: $15 | |||||
• Outpatient individual therapy visit: $15 | |||||
Rehabilitation services | |||||
• Occupational therapy visit: $15 | |||||
• Physical therapy and speech and language therapy visit: $15 | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: $15 | |||||
• Routine foot care: Not covered | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): 20% per item | |||||
• Diabetes supplies: 20% per item | |||||
Medicare Part B drugs | |||||
• Chemotherapy: 20% | |||||
• Other Part B drugs: 20% | |||||
** Benefits Services ** | |||||
Hearing | |||||
• Hearing exam: $15 | |||||
• Fitting/evaluation: $15 | |||||
• Hearing aids: $0 copay | |||||
Preventive dental | |||||
• Oral exam: Not covered | |||||
• Cleaning: Not covered | |||||
• Fluoride treatment: Not covered | |||||
• Dental x-ray(s): Not covered | |||||
Comprehensive dental | |||||
• Non-routine services: Not covered | |||||
• Diagnostic services: Not covered | |||||
• Restorative services: Not covered | |||||
• Endodontics: Not covered | |||||
• Periodontics: Not covered | |||||
• Extractions: Not covered | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered | |||||
Vision | |||||
• Routine eye exam: $0 copay | |||||
• Other: $0 copay | |||||
• Contact lenses: $0 copay | |||||
• Eyeglasses (frames and lenses): $0 copay | |||||
• Eyeglass frames: Not covered | |||||
• Eyeglass lenses: Not covered | |||||
• Upgrades: Not covered |