Blue Cross Medicare Advantage Core (PPO)

Medicare Advantage Plan for Minnesota

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PARTCRX

Plan Summary

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderBlue Cross Blue Shield of Minnesota
Plan IDH5959-1-0
CMS RatingNot Rated1
Plan TypePPO
Annual Deductible$405.00

What To Know About This Plan

  • This plan has health and drug coverage

Why We Like This Plan

  • has both Health and Drug Coverage

Plan Details

Costs and Other Important Information

Plan Year:
2018
Optional Supplemental Benefits
No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$10,000 In and Out-of-network $6,700 In-network
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$39.90
Monthly Health Plan Premium
$12.20

Benefits

Service
Cost
Inpatient hospital coverage
In-Network:
$400 for days 1 through 4
$0 for days 5 through 90
Out-of-Network:
40% per stay
Outpatient hospital coverage
In-Network:
20% per visit
Out-of-Network:
40% per visit
Doctor visits
Primary:
In-Network:
$20 per visit
Out-of-Network:
40% per visit
Specialist:
In-Network:
$50 per visit
Out-of-Network:
40% per visit
Preventive care
In-Network:
$0 copay
Out-of-Network:
40%
Emergency care/Urgent care
Emergency:
$80 per visit (always covered)
Urgent care:
$30 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
In-Network:
20%
Out-of-Network:
40%
Lab services:
In-Network:
$0 copay
Out-of-Network:
40%
Diagnostic radiology services (e.g., MRI):
In-Network:
20%
Out-of-Network:
40%
Outpatient x-rays:
In-Network:
20%
Out-of-Network:
40%
Mental health services
In-Network:
$400 for days 1 through 4
$0 for days 5 through 90
Out-of-Network:
40% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
40%
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
40%
Outpatient group therapy visit:
In-Network:
$40
Out-of-Network:
40%
Outpatient individual therapy visit:
In-Network:
$40
Out-of-Network:
40%
Skilled Nursing Facility
In-Network:
$0 for days 1 through 20
$165 for days 21 through 100
Out-of-Network:
40% per stay
Rehabilitation services
Occupational therapy visit:
In-Network:
$40
Out-of-Network:
40%
Physical therapy and speech and language therapy visit:
In-Network:
$40
Out-of-Network:
40%
Ambulance
In-Network:
20%
Out-of-Network:
40%
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:
In-Network:
$50
Out-of-Network:
40%
Routine foot care:
Not covered
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network:
20% per item
Out-of-Network:
40% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
40% per item
Diabetes supplies:
In-Network:
20% per item
Out-of-Network:
40% per item
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:
In-Network:
20%
Out-of-Network:
40%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
40%

Coverage Area for Blue Cross Medicare Advantage Core (PPO)

StateMinnesota
CountyRamsey

Cost Sharing Information

All cost-sharing assumes in-network healthcare providers.

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$8 copay$15 copayNot offered
Tier 2: Non-Preferred Generic$13 copay$20 copayNot offered
Tier 3: Preferred Brand Name16% coinsurance21% coinsuranceNot offered
Tier 4: Non-Preferred Brand Name45% coinsurance50% coinsuranceNot offered
Tier 5: Specialty Tier25% coinsurance25% coinsuranceNot offered
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$16 copay$30 copayNot offered
Tier 2: Non-Preferred Generic$26 copay$40 copayNot offered
Tier 3: Preferred Brand Name16% coinsurance21% coinsuranceNot offered
Tier 4: Non-Preferred Brand Name45% coinsurance50% coinsuranceNot offered
Tier 5: Specialty Tier25% coinsurance25% coinsuranceNot offered

Physician Finder

Physicians that accept Blue Cross Medicare Advantage Core (PPO) for Minnesota

/
YANG, PAOKOU
1504 WHITE BEAR AVE N
SAINT PAUL, MN 55106
KRAMER, LAURA
1710 SUBURBAN AVE
SAINT PAUL, MN 55106
HATLESTAD, PRESTON
1414 MARYLAND AVE E
SAINT PAUL, MN 55106
NICHOLSON, WILL
1414 MARYLAND AVE E
SAINT PAUL, MN 55106
BARSANTI, JOHN
911 MARYLAND AVE E
SAINT PAUL, MN 55106
DEVRIES, JASON
UFP PHALEN VILLAGE CLINIC
SAINT PAUL, MN 55106
KELLY, TARA
911 MARYLAND AVE E
SAINT PAUL, MN 55106
DALY, PATRICK
651 ARCADE ST
SAINT PAUL, MN 55106
GOERTZEN, TIMOTHY
166 4TH ST E
SAINT PAUL, MN 55101
MULCAHY, PAUL
166 4TH ST E
SAINT PAUL, MN 55101
MOLINARI, PAUL
640 JACKSON ST
SAINT PAUL, MN 55101
MUNDY, MATTHEW
640 JACKSON ST
SAINT PAUL, MN 55101
STELLPFLUG, SAMUEL
640 JACKSON ST
SAINT PAUL, MN 55101
HALLER, GLENN
640 JACKSON ST
SAINT PAUL, MN 55101
PEDERSON, PATRICK
640 JACKSON ST
SAINT PAUL, MN 55101
MIRANDA, ALLEN
640 JACKSON ST
SAINT PAUL, MN 55101
TURNER, MATTHEW
640 JACKSON ST
SAINT PAUL, MN 55101
LOUSHIN, MICHAEL
640 JACKSON ST
SAINT PAUL, MN 55101
FISHER, NANCY
166 4TH ST E
SAINT PAUL, MN 55101
WILLSON, MICHAEL
166 4TH ST E
SAINT PAUL, MN 55101
BUTTERMANN, ANN
640 JACKSON ST
SAINT PAUL, MN 55101
YOCHIM, PAUL
640 JACKSON ST
SAINT PAUL, MN 55101
LEE, DAVID
166 4TH ST E
SAINT PAUL, MN 55101
LAYMAN, MATTHEW
640 JACKSON ST
SAINT PAUL, MN 55101
SARPAL, RAJBIR
640 JACKSON ST
SAINT PAUL, MN 55101
Details
PAOKOU YANG, DPM
Phone Number
(651) 771-2513
Office Locations
1504 WHITE BEAR AVE N
SAINT PAUL, MN 55106
1504 WHITE BEAR AVE N SAINT PAUL MN, 55106

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