Platinum Blue Core Plan (Cost)
H2461 - 005 - 0
(4.5 / 5)
Platinum Blue Core 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 Core Plan (Cost) H2461 – 005 – 0 available in 21 County region.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Platinum Blue Core Plan (Cost) is offered in the following locations.
Plan Overview
Platinum Blue Core Plan (Cost) offers the following coverage and cost-sharing.
| Insurer: | Blue Cross and Blue Shield of Minnesota |
| Health Plan Deductible: | $0.00 |
| MOOP: | $6,000 In-network |
| Drugs Covered: | No |
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Premium Breakdown
Platinum Blue Core Plan (Cost) has a monthly premium of $34.00. 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 | $34.00 | $0.00 | $208.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Platinum Blue Core Plan (Cost) also provides the following benefits.
| $0 |
| In-network | No |
| $6,000 In-network |
| No |
| In-network | No |
| 20% coinsurance per visit (Authorization is not required.) (Referral is not required.) |
| Primary | $20 copay per visit (Not applicable.) (Not applicable.) |
| Specialist | $20 copay or 20% coinsurance 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 | $60 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | 20% coinsurance (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) | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
| Outpatient x-rays | $60 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 | $699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Cleaning | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Dental x-ray(s) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| 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 | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| 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 | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglasses (frames and lenses) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $20-40 copay (Authorization is not required.) (Referral is not required.) |
| 20% coinsurance (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $50 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.) |
| $600 per stay (Authorization is not required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $600 per stay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is not required.) (Referral is not required.) |
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Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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