2021 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Platinum Blue Choice Plan with Rx (Cost) | ||||
Location: | Koochiching, Minnesota Click to see other locations | ||||
Plan ID: | H2461 - 009 - 0 Click to see other plans | ||||
Member Services: | 1-651-662-5654 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
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— Medicare Plan Features — | |||||
Monthly Premium: | $134.50 (see Plan Premium Details below) | ||||
Annual Deductible: | $445 (Tier 1 and 2 excluded from the Deductible.) | ||||
Annual Initial Coverage Limit (ICL): | $4,130 | ||||
Health Plan Type: | Cost | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,500 | ||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,517 drugs | Browse the Platinum Blue Choice Plan with Rx (Cost) Formulary | |||
This plan has 5 drug tiers.
See cost-sharing for all pharmacies and tiers.
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Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $0.00 | $10.00 | 20% | 45% | 25% |
• Number of Drugs per Tier: | 426 | 871 | 770 | 727 | 723 |
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Koochiching, Minnesota: | 88 members | ||||
Number of Members enrolled in this plan in Minnesota: | 7,550 members | ||||
Number of Members enrolled in this plan in (H2461 - 009): | 7,591 members | ||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||
• 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 — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $14.90 | $21.30 | $27.70 | $34.10 |
— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | |||||
• Total monthly premium: $134.50 | |||||
• Health plan premium: $94 | |||||
• Drug plan premium: $40.50 | |||||
• You must continue to pay your Part B premium. | |||||
• Part B premium reduction: No | |||||
Deductible | |||||
• Health plan deductible: $0 | |||||
• Other health plan deductibles: In-network: No | |||||
• Drug plan deductible: $445.00 annual deductible | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $3,500 In-network | |||||
Optional supplemental benefits | |||||
• No | |||||
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? | |||||
• In-network: No | |||||
Doctor visits | |||||
• Primary: $5-15 copay per visit | |||||
• Specialist: $15 copay per visit (authorization required) | |||||
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 | |||||
Emergency care/Urgent care | |||||
• Emergency: $90 copay per visit (always covered) | |||||
• Urgent care: $25 copay per visit (always covered) | |||||
Inpatient hospital coverage | |||||
• $200 per stay | |||||
Outpatient hospital coverage | |||||
• $0-50 copay per visit | |||||
Skilled Nursing Facility | |||||
• $0 copay | |||||
Preventive care | |||||
• $0 copay | |||||
Ground ambulance | |||||
• $20 copay | |||||
Rehabilitation services | |||||
• Occupational therapy visit: $15 copay | |||||
• Physical therapy and speech and language therapy visit: $15 copay | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric: $200 per stay | |||||
• Outpatient group therapy visit with a psychiatrist: $15 copay | |||||
• Outpatient individual therapy visit with a psychiatrist: $15 copay | |||||
• Outpatient group therapy visit: $15 copay | |||||
• Outpatient individual therapy visit: $15 copay | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% coinsurance per item (authorization required) | |||||
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item | |||||
• Diabetes supplies: $0 copay | |||||
Hearing | |||||
• Hearing exam: $15 copay | |||||
• Fitting/evaluation: $15 copay (limits apply) | |||||
• Hearing aids: $599-899 copay (limits apply) | |||||
Preventive dental | |||||
• Oral exam: $0 copay (limits apply) | |||||
• Cleaning: $0 copay (limits apply) | |||||
• Fluoride treatment: Not covered | |||||
• Dental x-ray(s): $0 copay (limits apply) | |||||
Comprehensive dental | |||||
• Non-routine services: Not covered | |||||
• Diagnostic services: Not covered | |||||
• Restorative services: Not covered | |||||
• Endodontics: Not covered | |||||
• Periodontics: $0 copay (limits apply) | |||||
• Extractions: Not covered | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered | |||||
Vision | |||||
• Routine eye exam: $0 copay (limits apply) | |||||
• Other: Not covered | |||||
• Contact lenses: $0 copay (limits apply) | |||||
• Eyeglasses (frames and lenses): $0 copay (limits apply) | |||||
• Eyeglass frames: Not covered | |||||
• Eyeglass lenses: Not covered | |||||
• Upgrades: Not covered | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Transportation | |||||
• Not covered | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: $15 copay | |||||
• Routine foot care: Not covered | |||||
Medicare Part B drugs | |||||
• Chemotherapy: 20% coinsurance | |||||
• Other Part B drugs: 20% coinsurance |