2016
PLATINUM BLUE
WITH RX (COST)
SM
Medical and prescription drug benefits you want. Value you deserve.
OPTIONS YOU WANT
Platinum Blue can help pay the deductibles, copayments and
coinsurance Original Medicare doesn’t cover. And, with three medical
plan options available at different price points with different coverage
levels, you have a choice about how much coverage you need. You
can even add prescription drug coverage for greater convenience.
FLEXIBILITY FOR YOUR CHANGING LIFESTYLE
If you meet the eligibility requirements and are not locked in to your
current plan you can:
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Enroll in Platinum Blue anytime
COVERAGE WHEN YOU NEED IT,
WHERE YOU NEED IT
We want to keep you well wherever you are.
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See any provider in the large Platinum Blue network with no referral
needed. However, if you choose to see a out-of-network provider
you may only receive Original Medicare coverage for those services.
When you add our robust prescription drug coverage, you can fill
your prescriptions at more than 64,000 pharmacies nationwide,
or choose mail-order for greater cost savings
Travel for up to nine months throughout the United States and
receive in-network coverage for medically necessary services from
any provider that accepts Medicare
Costs incurred under the travel benefit apply toward your out-of­
pocket maximum
H2461_082515_Z01 CMS Accepted 08/30/2015
FIND THE PLAN
THAT’S RIGHT FOR YOU
CORE
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Lowest plan premium
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More copays and coinsurance
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Protection with an
out-of-pocket maximum
CHOICE
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Mid-priced premium
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Fewer copays and coinsurance
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Lower out-of-pocket maximum
COMPLETE
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Higher premium for more benefits
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Little or no copays or coinsurance
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Lower out-of-pocket maximum
OPTIONAL RX
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Part D prescription drug coverage
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Low copays and $0 on some generics
PLATINUM BLUE MEDICAL
BENEFITS OVERVIEW
The charts on these pages provide a snapshot
of Platinum Blue medical benefits. For more
detailed information including coverage limits that
may apply, refer to the Summary of Benefits found
in the 2016 enrollment kit and on our website at
bluecrossmn.com/medicare. You can also call us
at the number on the back page to request a copy.
MEDICAL BENEFIT CATEGORY
Monthly plan premium
You must also continue to pay your Part B premium
Deductible
Amount you pay before coverage begins
Doctor office visits
Primary care, specialists, chiropractic and podiatry services
Diagnostic tests, X-rays, lab services
and radiology services
Benefits shown are the amounts you pay for
in-network, Medicare-eligible services and supplies.
HELPFUL RESOURCES FOR HEALTHY HABITS
Good health is about taking time for your health every
day. We’ve identified habits that impact your health
and wellbeing: Managing stress, eating right, staying
active, managing a healthy weight, quitting tobacco,
and making health care decisions. The tools and
resources below are integrated into your health plan
benefits to help you create healthier habits and reach
your healthy goals.
Preventive services
“Welcome to Medicare” and Medicare-covered
annual wellness visits, annual physical examinations,
routine eye exams and routine hearing tests
LOOKING FOR ANSWERS?
Cancer screenings
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Health Guides
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Online health and wellbeing resources
Immunizations
Flu vaccine, hepatitis B vaccine (for people at risk),
pneumonia vaccine
Health and wellness education
UNDER THE WEATHER?
Nurse line
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SEEKING SUPPORT?
Quitting tobacco support
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SAVING MONEY?
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Silver&Fit Exercise and Healthy Aging Program
®
Emergency care
Urgently needed care
Within the United States
Inpatient hospital care
Skilled nursing facility care
Outpatient services/surgery
Ambulatory surgical center visits, outpatient hospital
facility visits
Prescription drugs
Part B drugs
Diabetes programs and supplies
Durable medical equipment, prosthetics
Annual medical out-of-pocket maximum
This information is not a complete description of benefits.
Limitations, copayments, and restrictions may apply.
PLATINUM BLUE CORE
PLATINUM BLUE CHOICE
PLATINUM BLUE COMPLETE
$29
$74
$109
$0
$0
$0
20% coinsurance
$15 copay
$0
$0
$0 for lab services, $0 to 20%
coinsurance for diagnostic procedures
and tests, 20% coinsurance for:
• X-rays
• Diagnostic radiology services
(not including X-rays)
• Therapeutic radiology services
$0
$0 for one Medicare-covered
annual wellness visit and one
physical examination per year and
one glaucoma screening; routine
eye exams and routine hearing tests
are not covered. No allowance for
eyewear or hearing aids.
$0 for one Medicare-covered
annual wellness visit, one physical
examination and one routine eye
exam per year; $15 copay for one
routine hearing test per year. Limited
allowance for eyewear and hearing
aids.
$0 for one Medicare-covered
annual wellness visit, one physical
examination, one routine eye exam
and one routine hearing test per year.
Limited allowance for eyewear and
hearing aids.
$0
$0
$0
$0; Original Medicare limits apply
$0; Original Medicare limits apply
$0; Original Medicare limits apply
• Silver&Fit Exercise and Healthy
• Silver&Fit Exercise and Healthy
• Silver&Fit Exercise and Healthy
Aging Program with fitness facility
Aging Program with fitness facility
Aging Program with fitness facility
membership or home exercise kit
membership or home exercise kit
membership or home exercise kit
options
options
options
• Nurse line included
• Nurse line included
• Nurse line included
• $0 for smoking cessation counseling • $0 for smoking cessation counseling • $0 for smoking cessation counseling
$50 copay
$50 copay
$0
$25 copay
$25 copay
$0
$500 copay per stay; plan covers
90 days each benefit period plus 60
lifetime reserve days
$100 copay per stay; no limit to the
number of days covered each benefit
period
$0; no limit to the number of days
covered each benefit period
Days 1 – 20: $0
Days 21 – 100: $150 copay per day
$0 for up to 100 days each
benefit period
$0 for up to 100 days each
benefit period
20% coinsurance
$0 to $50 copay
$0
20% coinsurance
20% coinsurance
0 – 20% coinsurance; Does not apply
to drugs administered during an office
visit
$0 for self-management training;
20% coinsurance for supplies
$0 for self-management training;
20% coinsurance for supplies
$0
20% coinsurance
20% coinsurance
$0
$5,000
$3,000
$3,000
Contact the plan for more information.
OPTIONAL PRESCRIPTION DRUG COVERAGE OVERVIEW
COVERAGE CATEGORY
PLATINUM BLUE
CORE WITH RX
PLATINUM BLUE
CHOICE WITH RX
PLATINUM BLUE
COMPLETE WITH RX
Monthly plan premiums
You must also continue to pay
your Part B premium
$38.90
($29.00 medical +
$9.90 Rx)
$103.40
($74.00 medical +
$29.40 Rx)
$164.50
($109.00 medical +
$55.50 Rx)
Deductible
Amount you pay for prescription
drugs before coverage begins
$360
$360, applies to
Tiers 3 – 5 only
$360, applies to
Tiers 3 – 5 only
$4
$13
$40
50%
25%
$0
$5
$15
$40
50%
25%
$2
$3
$10
$35
50%
25%
$0
Initial coverage
Amount you pay for a 30-day
supply after paying the annual
deductible
• Tier 1: Preferred Generic
• Tier 2: Non-Preferred Generic
• Tier 3: Preferred Brand
• Tier 4: Non-Preferred Brand
• Tier 5: Specialty Drugs
• Tier 6: Select Care Drugs
Coverage gap
Amount you pay for a 30-day
supply after your total yearly
drug costs reach $3,310
58% of the plan’s costs for covered generic drugs
45% of the plan’s costs for covered brand name drugs
Catastrophic coverage
Amount you pay for a 30-day
supply after your total yearly
out-of-pocket drug costs
reach $4,850
The greater of $2.95 copay for covered generic and $7.40 copay for all
other covered drugs or 5% of the cost of covered drugs
PLATINUM BLUE WITH RX DRUG FORMULARY
HELPFUL INFORMATION
The Platinum Blue Formulary lists drugs covered by
Platinum Blue.
Coverage gap
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Check the printed formulary or the online drug cost
calculator to see if your medications are covered
Review the six different tiers of covered drugs.
This will determine the amount you will pay for
your drugs.
The formulary can change throughout the year.
For the most up-to-date formulary, call member
services or use the online drug cost calculator at
myprime.com.
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Your “total yearly drug costs” represents the total
amount you have paid for covered drugs plus what
the plan has paid for the calendar year. This does
not include the plan premium you pay.
The brand-name drug coverage in the coverage
gap is subject to agreements between Centers
for Medicare & Medicaid Services (CMS) and
drug manufacturers. Not all brand drugs may be
discounted. Call us if you have any questions.
Catastrophic coverage
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Your “out-of-pocket costs” means the amount you
have paid for covered drugs for the calendar year.
This does not include the amount the plan has paid
or the plan premium you pay.
MORE CONVENIENCE WITH BUILT-IN
OPTIONAL DRUG COVERAGE
Platinum Blue members can roll their medical and
prescription drug coverage into one easy-to-use plan.
When you purchase a Platinum Blue with Rx plan,
you’ll have greater:
Ease of use
Affordability
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One member ID card for medical and
prescription drugs
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One customer service center
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One billing system
Mail-order up to three-month supply for extra
savings
Convenience
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Affordable premiums and copays
64,000 in-network pharmacies nationwide
Coverage when you travel continuously for up to
nine months outside of Minnesota
Eligibility and enrollment: You are eligible to enroll
in Platinum Blue if you have Medicare Part A and
Medicare Part B (or have Medicare Part B only) and
reside in Minnesota. You can be a member of only
one Medicare Advantage or Medicare Cost plan
at a time. By enrolling in Platinum Blue, you will
automatically be disenrolled from any other Medicare
Advantage or Medicare Cost plan of which you are a
member. You may not be eligible to enroll if you have
permanent end-stage renal disease (kidney disease
requiring dialysis or a kidney transplant) unless you
are currently enrolled in a Blue Cross and Blue Shield
of Minnesota plan.
Provider network: Blue Cross has formed a
contracted network of doctors, specialists, hospitals
and other providers for Platinum Blue. You can use
any provider who is part of this network without a
referral. The health care providers in the network may
change at any time. You may search for providers on
our website, request a provider directory or contact
us at the number below to see if your providers are
in the network. Each provider is an independent
contractor and is not our agent.
Beginning with your effective date, to receive the
highest level of benefits while in the service area,
you must get all of your health care from network
providers, with the exception of emergency and
urgently needed services. If you go to a provider
outside of the Platinum Blue network (in the plan’s
service area) who accepts Medicare patients, your
coverage will be the same as Original Medicare.
Original Medicare deductibles, copayments and
coinsurance apply. You will receive in-network
benefits for eligible services received outside the
service area within the United States for up to nine
(9) months each year. In addition to being covered in
the United States, emergency services are covered
worldwide.
Prescription drugs, formulary, pharmacy network,
mail order service: If you enroll in Platinum Blue
with Rx, you must receive your Medicare prescription
drug coverage through this plan. Drug coverage
benefits are subject to limitations.
Prescription drugs, without optional Rx plan:
Other than those covered by Medicare Part B,
Platinum Blue does not include coverage for
prescription drugs. If you enroll in Platinum Blue and
want prescription drug coverage, you must enroll in
either the Platinum Blue with Rx prescription drug plan
or a separate Medicare Part D prescription drug plan
for an additional monthly premium. MedicareBlue
Rx is a stand-alone prescription drug plan with a
Medicare contract. Enrollment in MedicareBlue Rx
depends on contract renewal. To learn more, contact
a Blue Cross Medicare consultant or your local
licensed agent.
Federal contract: Platinum Blue is a Cost plan with
a Medicare contract. Enrollment in Platinum Blue
depends on contract renewal. Enrollment in the plan
after December 31, 2016, cannot be guaranteed.
Either CMS or the plan may choose not to renew the
contract, or the plan may choose to change the area
it serves. Any such change may result in termination
of your enrollment. Benefits, premiums and/or
copayments/coinsurance may change on January 1
of each year. The formulary, pharmacy network and/
or provider network may change at any time. You will
receive notice when necessary.
Plan ratings: Medicare rates how well plans
perform in such areas as detecting and preventing
illness, and customer service. The ratings are online
at medicare.gov, or see the enrollment kit, visit our
website or call us at the number below to get a copy.
Learn more: To learn more about any of the
important information in this benefits overview,
contact a Blue Cross Medicare consultant or your
local licensed agent. Information is also available
online at bluecrossmn.com/medicare or by
writing: Platinum Blue, P.O. Box 64024, St. Paul,
MN 55164-0024. You may also contact Medicare at
1-800-633-4227, 24 hours a day, 7 days a week. TTY
users should call 1-877-486-2048.
The Silver&Fit program is provided by American
Specialty Health Fitness, Inc., a subsidiary of
American Specialty Health Incorporated (ASH), an
independent company providing personal health and
wellness programs. Silver&Fit is a federally registered
trademark of ASH and used with permission herein.
Prime Therapeutics LLC is an independent company
providing pharmacy benefit management services.
Contact a Blue Cross Medicare
consultant or your local
licensed agent.
1-877-662-2583 / TTY 711
8 a.m. to 8 p.m. Central Time, daily
bluecrossmn.com/medicare
Blue Cross® and Blue Shield ® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.
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