Platinum Blue Choice Plan (Cost)
H2461 - 006 - 0
(4.5 / 5)
Platinum Blue Choice Plan (Cost) is a Medicare Advantage (Part C) Plan by Blue Cross and Blue Shield of Minnesota.
This page features plan details for 2024 Platinum Blue Choice Plan (Cost) H2461 – 006 – 0 available in 21 County Region.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Platinum Blue Choice Plan (Cost) is offered in the following locations.
Plan Overview
Platinum Blue Choice Plan (Cost) offers the following coverage and cost-sharing.
| Insurer: | Blue Cross and Blue Shield of Minnesota |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,500 In-network |
| Drugs Covered: | No |
Ready to sign up for Platinum Blue Choice Plan (Cost) ?
Premium Breakdown
Platinum Blue Choice Plan (Cost) has a monthly premium of $119.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $119.00 | $0.00 | $293.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Platinum Blue Choice Plan (Cost) also provides the following benefits.
| $0 |
| In-network | No |
| $3,500 In-network |
| No |
| In-network | No |
| $0-50 copay per visit (Authorization is not required.) (Referral is not required.) |
| Primary | $0-15 copay per visit (Not applicable.) (Not applicable.) |
| Specialist | $15 copay per visit (Authorization is required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $95 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $15 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0 copay (Authorization is not required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is not required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient x-rays | $0 copay (Authorization is not required.) (Referral is not required.) |
| Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $599-899 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $15 copay (Authorization is not required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $15 copay (Authorization is not required.) (Referral is not required.) |
| $20 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $15 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is not required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $0-35 copay (Authorization is required.) (Not applicable.) |
| $200 per stay (Authorization is not required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $200 per stay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $15 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $15 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $15 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $15 copay (Authorization is not required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $0 per day for days 21 through 100 (Authorization is not required.) (Referral is not required.) |
Ready to sign up for Platinum Blue Choice Plan (Cost) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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