What To Know About This Plan
- This is a health coverage only plan with no drug coverage
Costs and Other Important Information
Prescription Drug Coverage
Drugs Covered under Medicare Part B
Most drugs not covered.
20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.
Drugs Covered under Medicare Part D
This plan does not offer prescription drug coverage.
Doctor and Hospital Choice
No referral required for network doctors, specialists, and hospitals.
In and Out-of-Network
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share, you pay the Medicare Part B deductible and coinsurance.
Out of Service Area
Plan covers you when you travel in the U.S. or its territories.
Inpatient Hospital Care
No limit to the number of days covered by the plan each hospital stay.
$100 copay for each Medicare-covered hospital stay
$0 copay for additional non-Medicare-covered hospital days
Inpatient Mental Health Care
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.
$100 copay for each Medicare-covered hospital stay.
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.
Skilled Nursing Facility (SNF)
Plan covers up to 100 days each benefit period
$0 copay for SNF services
Home Health Care
$0 copay for Medicare-covered home health visits
You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.
Doctor Office Visits
$15 copay for each Medicare-covered primary care doctor visit.
$15 copay for each Medicare-covered specialist visit.
Outpatient Medical Services and Supplies
$15 copay for each Medicare-covered chiropractic visit
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).
$15 copay for each Medicare-covered podiatry visit
Medicare-covered podiatry visits are for medically necessary foot care.
Outpatient Mental Health Care
$15 copay for each Medicare-covered individual therapy visit
$15 copay for each Medicare-covered group therapy visit
$15 copay for each Medicare-covered individual therapy visit with a psychiatrist
$15 copay for each Medicare-covered group therapy visit with a psychiatrist
$15 copay for Medicare-covered partial hospitalization program services
Outpatient Substance Abuse Care
$15 copay for Medicare-covered individual substance abuse outpatient treatment visits
$15 copay for Medicare-covered group substance abuse outpatient treatment visits
$50 copay for each Medicare-covered ambulatory surgical center visit
$0 to $50 copay for each Medicare-covered outpatient hospital facility visit
$25 copay for Medicare-covered ambulance benefits.
$50 copay for Medicare-covered emergency room visits
If you are admitted to the hospital within 24-hour(s) for the same condition, you pay $0 for the emergency room visit.
Urgently Needed Care
$25 copay for Medicare-covered urgently-needed-care visits
Outpatient Rehabilitation Services
Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered.
$15 copay for Medicare-covered Occupational Therapy visits
$15 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits
Durable Medical Equipment
20% of the cost for Medicare-covered durable medical equipment
20% of the cost for Medicare-covered prosthetic devices
20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices
Diabetes Programs and Supplies
$0 copay for Medicare-covered Diabetes self-management training
20% of the cost for Medicare-covered Diabetes monitoring supplies
20% of the cost for Medicare-covered Therapeutic shoes or inserts
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
$0 copay for Medicare-covered:
- lab services
- diagnostic procedures and tests
- diagnostic radiology services (not including X-rays)
- therapeutic radiology services
Cardiac and Pulmonary Rehabilitation Services
$15 copay for Medicare-covered Cardiac Rehabilitation Services
$15 copay for Medicare-covered Intensive Cardiac Rehabilitation Services
$15 copay for Medicare-covered Pulmonary Rehabilitation Services
$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.
$0 copay for a supplemental annual physical exam
Kidney Disease and Conditions
Cost plan members pay Original Medicare cost sharing for out-of-area dialysis.
$15 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
In general, preventive dental benefits (such as cleaning) not covered.
$15 copay for Medicare-covered dental benefits
$0 copay for supplemental hearing aids.
$15 copay for Medicare-covered diagnostic hearing exams
$15 copay for up to 1 supplemental routine hearing exam(s) every year
$15 copay for up to 1 supplemental hearing aid fitting-evaluation(s) every year
$450 plan coverage limit for supplemental hearing aids every year.
$0 to $15 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk
$0 copay for up to 1 supplemental routine eye exam(s) every year
20% of the cost for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery.
0% of the cost for eyeglasses (lenses and frames)
0% of the cost for contact lenses
$125 plan coverage limit for supplemental eyewear every year
Staying healthy - screenings, tests and vaccines
Managing Chronic Conditions
Ratings of Plan Responsiveness and Care
Member Complaints, Problems Getting Services, and Choosing to Leave the Plan
Physicians that accept Platinum Blue Choice (Cost) for Minnesota