Platinum Blue Choice Plan with Rx (Cost)
Available to residents of Pine County, MN for 2026. Contract H2461, plan 009, segment 0.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Pine County
- Plan website
- Browse the Platinum Blue Choice Plan with Rx (Cost) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $227.00 |
|---|---|
| — medical (Part C) part | $142.00 |
| — drug (Part D) part | $85.00? |
| Monthly premium with full Extra Help (LIS) | $185.50?drug (Part D) part $43.50; Extra Help does not cover the medical (Part C) premium |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $3,900.00? |
| Drug deductible | $615.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | Cost? |
| Contract / plan | H2461-009-0 |
| Offered by | Blue Cross and Blue Shield of Minnesota |
| Parent organization | Aware Integrated, Inc. |
| Formulary drugs | 3,539 |
| Formulary exception tier | 4? |
| Pharmacy search | www.myprime.com |
| Member services | (877)662-2583TTY 711 |
CMS star ratings
- Overall
- 3.5 out of 5 stars for Overall
- Health plan (Part C)
- 3.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H2461 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $20 copay |
| Other health care professional | $15 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $0 copay |
| Lab services | $0 copay |
| Diagnostic radiology (e.g. MRI, CT) | $0 copay |
| Therapeutic radiology | $0 copay |
| Outpatient x-rays | $0 copay |
| Emergency and urgent care | |
| Emergency room | $100 copay |
| Urgent care | $15 copay |
| Worldwide emergency coverage | $100 copay |
| Worldwide urgent care | Not covered |
| Worldwide emergency transportation | $100 copay |
| Hospital care | |
| Inpatient hospital stay | $350 per stay |
| Outpatient hospital services | $0–$150 copay |
| Outpatient observation | $150 copay |
| Ambulatory surgical center | $50 copay |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $218 per day for days 21–100 |
| Home health care | $0 copay |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $15 copay |
| Physical therapy and speech-language therapy | $15 copay |
| Cardiac rehabilitation | $0 copay |
| Pulmonary rehabilitation | $0 copay |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $350 per stay |
| Outpatient mental health, individual session | $0 copay |
| Outpatient mental health, group session | $0 copay |
| Psychiatrist, individual session | $0 copay |
| Psychiatrist, group session | $0 copay |
| Partial hospitalization | $15 copay |
| Intensive outpatient program | $15 copay |
| Outpatient substance use, individual session | $0 copay |
| Outpatient substance use, group session | $0 copay |
| Opioid treatment program | $15 copay |
| Ambulance and transportation | |
| Ground ambulance | $300 copay |
| Air ambulance | $300 copay |
| Transportation to plan-approved locations | Not covered |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20%–40% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance |
| Medical supplies | 20% coinsurance |
| Diabetes supplies | $0 copay |
| Diabetic therapeutic shoes or inserts | 20% coinsurance |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay |
| Routine chiropractic care | Not covered |
| Acupuncture | $15 copay(limits apply) |
| Foot exams and treatment (Medicare-covered) | $15 copay |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $15 copay(authorization required) |
| Preventive dental plan limit | $1,000 plan limit every year |
| Oral exams | $0 copay(authorization required, limits apply) |
| Cleanings | $0 copay(authorization required, limits apply) |
| Fluoride treatment | $0 copay(authorization required, limits apply) |
| Dental x-rays | $0 copay(authorization required, limits apply) |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | Not covered |
| Restorative services (fillings, crowns) | Not covered |
| Endodontics (root canals) | Not covered |
| Periodontics (gum disease) | $0 copay(authorization required, limits apply) |
| Dentures and other removable prosthodontics | Not covered |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | Not covered |
| Oral and maxillofacial surgery | Not covered |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay(authorization required) |
| Vision? | |
| Eye exam (Medicare-covered) | $0 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | 20% coinsurance(limits apply) |
| Eyewear plan limit | $125 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $0 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay |
| Hearing aids (all types) | $599–$899 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | $0–$35 copay(authorization required) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required) |
| Other Part B drugs | 0%–20% coinsurance(authorization required) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $50 allowance every three months |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay |
| Health education | $0 copay |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $0.00 |
| Tier 3 | 23% |
| Tier 4 | 44% |
| Tier 5 | 25% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | 23% | 23% | 23% | 23% | 23% | 23% |
| Tier 4: Non-Preferred Drug | 44% | 44% | 44% | 44% | 44% | 44% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 20 other MN counties
Benefits in plain text
Platinum Blue Choice Plan with Rx (Cost) (H2461-009-0) is a 2026 Cost Medicare Advantage plan offered by Blue Cross and Blue Shield of Minnesota, available to residents of Pine County, MN.
The monthly premium is $227.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $185.50.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $3,900.00.
The drug deductible is $615.00. Tier 1 and 2 exempt.
The plan's formulary lists 3,539 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $0.00; tier 3: 23%; tier 4: 44%; tier 5: 25%.
CMS gives the plan's contract (H2461) an overall rating of 3.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.