NextBlue Summit PPO (PPO)

Available to residents of Grand Forks County, ND for 2026. Contract H6202, plan 005, segment 0.

New for 2026. This plan has no 2025 predecessor in the CMS crosswalk.

Plan details

Monthly premium (Part C + D)	$149.00
— medical (Part C) part	$89.30
— drug (Part D) part	$59.70?
Monthly premium with full Extra Help (LIS)	$119.20?drug (Part D) part $29.90; Extra Help does not cover the medical (Part C) premium
Part B premium reduction (giveback)	None
In-network out-of-pocket maximum	$6,750.00?
In- and out-of-network out-of-pocket maximum	$6,750.00
Drug deductible	$300.00Tier 1 and 2 exempt
Drug out-of-pocket threshold	$2,100.00
Plan type	PPO?
Contract / plan	H6202-005-0
Offered by	NextBlue of North Dakota
Parent organization	Blue Cross Blue Shield of Michigan Mutual Ins. Co.
Formulary drugs	3,083
Formulary exception tier	4?
Pharmacy search	www.nextblueND.com/pharmacies
Member services	(844)753-5678TTY 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 H6202 shares this rating.

Plan health benefits

Service	In-network	Out-of-network?
Doctor visits
Primary care doctor	$0 copay	$0 copay
Specialist	$45 copay	$45 copay
Other health care professional	$0–$45 copay	$0–$45 copay
Additional telehealth services	$0–$50 copay	—
Preventive care
Medicare-covered preventive services	$0 copay	$0 copay
Annual physical exam	$0 copay	$0 copay
Kidney disease education	$0 copay	$0 copay
Glaucoma screening	$0 copay	$0 copay
Diabetes self-management training	$0 copay	$0 copay
Diagnostic tests, labs and imaging
Diagnostic tests and procedures	$0–$175 copay(authorization required)	$0–$175 copay
Lab services	$10 copay(authorization required)	$10 copay
Diagnostic radiology (e.g. MRI, CT)	$0–$400 copay(authorization required)	$0–$400 copay
Therapeutic radiology	20% coinsurance(authorization required)	20% coinsurance
Outpatient x-rays	$20 copay(authorization required)	$20 copay
Emergency and urgent care
Emergency room	$125 copay	—
Urgent care	$50 copay	—
Worldwide emergency coverage	$125 copay · $50,000 plan limit	—
Worldwide urgent care	$50 copay · $50,000 plan limit	—
Worldwide emergency transportation	$125 copay	—
Hospital care
Inpatient hospital stay	$425 per day for days 1–4; $0 per day for days 5–90(authorization required)	$425 per day for days 1–4; $0 per day for days 5–90
Outpatient hospital services	$350–$400 copay(authorization required)	$350–$400 copay
Outpatient observation	$300 copay(authorization required)	$300 copay
Ambulatory surgical center	$175 copay(authorization required)	$175 copay
Outpatient blood services	$0 copay	$0 copay
Skilled nursing and home health
Skilled nursing facility	$0 per day for days 1–20; $200 per day for days 21–55; $0 per day for days 56–100(authorization required)	$0 per day for days 1–20; $200 per day for days 21–55; $0 per day for days 56–100
Home health care	$0 copay(authorization required)	$0 copay
Kidney dialysis	20% coinsurance	20% coinsurance
Rehabilitation
Occupational therapy	$45 copay	$45 copay
Physical therapy and speech-language therapy	$45 copay	$45 copay
Cardiac rehabilitation	$30 copay	$30 copay
Pulmonary rehabilitation	$25 copay	$25 copay
Mental health and substance use
Inpatient psychiatric hospital stay	$425 per day for days 1–4; $0 per day for days 5–90(authorization required)	$425 per day for days 1–4; $0 per day for days 5–90
Outpatient mental health, individual session	$45 copay	$45 copay
Outpatient mental health, group session	$45 copay	$45 copay
Psychiatrist, individual session	$45 copay	$45 copay
Psychiatrist, group session	$45 copay	$45 copay
Partial hospitalization	$95 copay(authorization required)	$95 copay
Intensive outpatient program	$95 copay(authorization required)	$95 copay
Outpatient substance use, individual session	$45 copay	$45 copay
Outpatient substance use, group session	$45 copay	$45 copay
Opioid treatment program	$0 copay(authorization required)	$0 copay
Ambulance and transportation
Ground ambulance	$250 copay(authorization required)	$250 copay
Air ambulance	20% coinsurance(authorization required)	20% coinsurance
Transportation to plan-approved locations	Not covered	—
Medical equipment and supplies
Durable medical equipment (e.g. wheelchairs, oxygen)	0%–20% coinsurance(authorization required)	0%–20% coinsurance
Prosthetics (e.g. braces, artificial limbs)	20% coinsurance(authorization required)	20% coinsurance
Medical supplies	20% coinsurance(authorization required)	20% coinsurance
Diabetes supplies	$0 copay	$0 copay
Diabetic therapeutic shoes or inserts	20% coinsurance	20% coinsurance
Chiropractic, acupuncture and foot care
Chiropractic (Medicare-covered)	$15 copay	$15 copay
Routine chiropractic care	$30 copay	$30 copay
Acupuncture	Not covered	—
Foot exams and treatment (Medicare-covered)	$45 copay	$45 copay
Routine foot care	Not covered	—
Dental?
Medicare-covered dental services	$45 copay	$45 copay
Preventive dental plan limit	$650 plan limit every year	—
Oral exams	$0 copay	$0 copay
Cleanings	$0 copay	$0 copay
Fluoride treatment	$0 copay	$0 copay
Dental x-rays	$0 copay	$0 copay
Other diagnostic dental services	$0 copay	$0 copay
Other preventive dental services	$0 copay	$0 copay
Restorative services (fillings, crowns)	$0 copay	$0 copay
Endodontics (root canals)	$0 copay	$0 copay
Periodontics (gum disease)	$0 copay	$0 copay
Dentures and other removable prosthodontics	$0 copay	$0 copay
Maxillofacial prosthetics	$0 copay	$0 copay
Implants	$0 copay	$0 copay
Bridges and other fixed prosthodontics	$0 copay	$0 copay
Oral and maxillofacial surgery	$0 copay	$0 copay
Orthodontics	$0 copay	$0 copay
Adjunctive general services	Not covered	—
Vision?
Eye exam (Medicare-covered)	$0–$45 copay	$0–$45 copay
Routine eye exam	$0 copay(limits apply)	50% coinsurance
Eyewear after cataract surgery (Medicare-covered)	$0 copay(limits apply)	—
Eyewear plan limit	$650 plan limit every year	—
Contact lenses	$0 copay(limits apply)	$0 copay
Eyeglasses (frames and lenses)	$0 copay(limits apply)	$0 copay
Eyeglass lenses	$0 copay(limits apply)	$0 copay
Eyeglass frames	$0 copay(limits apply)	$0 copay
Eyewear upgrades	$0 copay(limits apply)	$0 copay
Hearing?
Hearing exam (Medicare-covered)	$0–$45 copay	$0–$45 copay
Routine hearing exam	$0 copay(limits apply)	$0 copay
Hearing aid fitting and evaluation	$0 copay	$0 copay
Hearing aid plan limit	$650 plan limit every year	—
Hearing aids (all types)	$0 copay(limits apply)	$0 copay
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	$35 copay(authorization required, step therapy may apply)	$35 copay
Chemotherapy and radiation drugs	0%–20% coinsurance(authorization required, step therapy may apply)	20% coinsurance
Other Part B drugs	0%–20% coinsurance(authorization required, step therapy may apply)	35% coinsurance
Other extra benefits?
Over-the-counter (OTC) allowance	Not covered	—
Meals after a hospital stay or for a chronic condition	Not covered	—
Fitness benefit	Not covered	—
Health education	Not covered	—
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	$0 copay
Home and bathroom safety devices	Not covered	—
Counseling services	Not covered	—
In-home safety assessment	Not covered	—
Personal emergency response system (PERS)	$0 copay	$0 copay
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; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.

Drug tiers — preferred pharmacy, initial coverage

Tier	Cost-sharing
Tier 1	$0.00
Tier 2	$3.00
Tier 3	20%
Tier 4	25%
Tier 5	29%

Rx cost-sharing by coverage phase

Tier	30-day supply			90-day supply
Tier	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	$3.00	$3.00	$3.00	$9.00	$9.00	$7.50
Initial coverage phase
Tier 1: Preferred Generic	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 2: Generic	$3.00	$3.00	$3.00	$9.00	$9.00	$7.50
Tier 3: Preferred Brand	20%	20%	20%	20%	20%	20%
Tier 4: Non-Preferred Drug	25%	25%	25%	25%	25%	25%
Tier 5: Specialty Tier	29%	29%	29%	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 52 other ND counties

Benefits in plain text

NextBlue Summit PPO (PPO) (H6202-005-0) is a 2026 PPO Medicare Advantage plan offered by NextBlue of North Dakota, available to residents of Grand Forks County, ND.

The monthly premium is $149.00 (Part C and Part D together).

With full Extra Help (the Low-Income Subsidy), the total monthly premium is $119.20.

Its in-network out-of-pocket maximum is $6,750.00.

The combined in- and out-of-network out-of-pocket maximum is $6,750.00.

The drug deductible is $300.00. Tier 1 and 2 exempt.

The plan's formulary lists 3,083 drugs.

At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $3.00; tier 3: 20%; tier 4: 25%; tier 5: 29%.

CMS gives the plan's contract (H6202) 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.