Platinum Blue Choice Plan with Rx (Cost)

H2461 - 009 - 0
4.5 out of 5 stars (4.5 / 5)

Platinum Blue Choice Plan with Rx (Cost) is a Medicare Advantage Plan by Blue Cross and Blue Shield of Minnesota.

This page features plan details for 2025 Platinum Blue Choice Plan with Rx (Cost) H2461 – 009 – 0 available in 21 County Region.

Locations

Platinum Blue Choice Plan with Rx (Cost) is offered in the following locations.

Plan Overview

Platinum Blue Choice Plan with Rx (Cost) offers the following coverage and cost-sharing.

Insurer:Blue Cross and Blue Shield of Minnesota
Health Plan Deductible:$0
MOOP:$3,500 In-network
Drugs Covered:Yes

Ready to sign up for Platinum Blue Choice Plan with Rx (Cost) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Platinum Blue Choice Plan with Rx (Cost) has a monthly premium of $176.20. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $129.00 $47.20 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Platinum Blue Choice Plan with Rx (Cost) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $590.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$47.20$19.50

Initial Coverage Phase

After you pay your $590.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Platinum Blue Choice Plan with Rx (Cost) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – No Co pay (Limits Apply, Authorization Required)
  • Periodontics
    • In-Network: No Coins – No Co pay (Authorization Required)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay (Authorization Required)
  • Fluoride Treatment
    • In-Network: No Coins – No Copay (Authorization Required)
  • Oral Exams
    • In-Network: No Coins – No Copay (Authorization Required)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay (Authorization Required)

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • $0 copay
  • Outpatient x-rays
    • $0 copay
  • Diagnostic tests and procedures
    • $0 copay
  • Lab services
    • $0 copay

Doctor visits

  • Specialist
    • $15 copay per visit (Authorization Required)
  • Primary
    • $0 copay

Emergency care/Urgent care

  • Emergency
    • $100 copay per visit (always covered)
  • Urgent care
    • $15 copay per visit (always covered)

Foot care (podiatry services)

  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • $15 copay

Ground ambulance

    • $100 copay

Health plan deductible

    • $0

Hearing

  • Medicare-Covered Hearing Exam
    • $0 copay
  • Hearing aids OTC
    • Not covered
  • Hearing aids
    • $599-899 copay (Limits Apply)
  • Fitting/evaluation
    • $0 copay

Inpatient hospital coverage

    • $200 per stay

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $3,500 In-network

Medical equipment/supplies

  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • 20-40% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • $0 copay
  • Prosthetics (e.g., braces, artificial limbs)
    • 20% coinsurance per item

Medicare Part B drugs

  • Chemotherapy
    • 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • 0-20% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit
    • $0 copay
  • Outpatient group therapy visit with a psychiatrist
    • $0 copay
  • Inpatient hospital – psychiatric
    • $200 per stay
  • Outpatient individual therapy visit with a psychiatrist
    • $0 copay
  • Outpatient individual therapy visit
    • $0 copay

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • $0-50 copay per visit

Preventive care

    • $0 copay

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • $15 copay
  • Occupational therapy visit
    • $15 copay

Skilled Nursing Facility

    • $0 per day for days 1 through 20
      $0 per day for days 21 through 100

Transportation

    • Not covered

Vision

  • Eyeglass frames
    • $0 copay (Limits Apply)
  • Eyeglass lenses
    • $0 copay (Limits Apply)
  • Routine eye exam
    • $0 copay (Limits Apply)
  • Upgrades
    • Not covered
  • Contact lenses
    • $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • $0 copay (Limits Apply)
  • Other
    • Not covered

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for Platinum Blue Choice Plan with Rx (Cost) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Platinum Blue Choice Plan with Rx (Cost)? See 2025 Platinum Blue Choice Plan with Rx (Cost) at MedicareAdvantageRX.com.

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