Platinum Blue Core Plan with Rx (Cost)
Health Insurance Company: Blue Cross and Blue Shield of Minnesota
Medicare Advantage Plan Details
- Rx
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Emergency Room
$125 copay per visit (always covered)
Ambulance Coverage
20% coinsurance
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: $25 copay
Medicare-covered lab services: $0 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): 20% coinsurance
Medicare-covered x-ray services: $60 copay
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: 20% coinsurance per visit
Hospitalization Coverage
Inpatient hospital-acute:
$600 per stay
Inpatient hospital psychiatric:
$600 per stay
Rehabilitation Coverage
Occupational therapy services:
$40 copay
Physical therapy and speech and language therapy services:
$40 copay
Urgent Care Coverage
$55 copay per visit (always covered)
Skilled Nursing Facility (SNF)
$0 per day for days 1 through 20
$214 per day for days 21 through 100
Mental Health Coverage
Medicare-covered individual sessions: $20 copay
Medicare-covered group sessions: $20 copay
Dental, Vision, Hearing Benefits
Vision Benefits
Eye exams:
Routine eye exams: Not covered
Eyewear:
Contact Lenses: Not covered
Eyeglasses: Not covered
Hearing Benefits
Hearing exams:
Routine hearing exams: $0 copay
Hearing aids:
Hearing aids (all types): $699-999 copay
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$5.00 copay (30-day supply)
$10.00 copay (90-day supply)
Tier 3: Preferred Brand
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
44% coinsurance (30-day supply)
44% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$5.00 copay (30-day supply)
$10.00 copay (90-day supply)
Tier 2: Generic
$10.00 copay (30-day supply)
$20.00 copay (90-day supply)
Tier 3: Preferred Brand
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
46% coinsurance (30-day supply)
46% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Preferred Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$5.00 copay (30-day supply)
$10.00 copay (90-day supply)
Tier 3: Preferred Brand
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
44% coinsurance (30-day supply)
44% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
More Additional Benefits
Plan Links
Ready to Enroll Online?
Or call and get free advice from licensed insurance agents
Looking for other plans in your area?