Platinum Blue Complete Plan with Rx (Cost)

Platinum Blue Complete Plan with Rx (Cost) H2461-010 Plan Details
4 out of 5 stars

Platinum Blue Complete Plan with Rx (Cost) is a Medicare Advantage (Medicare Part C) plan offered by Aware Integrated, Inc..
Plan ID: H2461-010.

$232.50
Monthly Premium

Platinum Blue Complete Plan with Rx (Cost) is a Medicare Advantage (Medicare Part C) plan offered by Aware Integrated, Inc..
Plan ID: H2461-010.

Platinum Blue Complete Plan with Rx (Cost) H2461-010 Plan Details
4 out of 5 stars

Platinum Blue Complete Plan with Rx (Cost) is a Medicare Advantage (Medicare Part C) plan offered by Aware Integrated, Inc..
Plan ID: H2461-010.

$232.50
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $480
Out of Pocket Max In-Network: $2700
Out-of-Network: 0
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $100.00
Your plan covers an unlimited number of days for an inpatient stay.
Urgent Care
Copayment for Urgent Care $0.00
Emergency Room Visit
Copayment for Emergency Care $0.00

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $0.00
Copayment for Worldwide Emergency Transportation $0.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $0.00

Air Ambulance:
Copayment for Air Ambulance Services $0.00

Health Care Services and Medical Supplies

Platinum Blue Complete Plan with Rx (Cost) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $0.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Durable Medical Eqipment (DME)
In-Network:
Copayment for Medicare-covered Durable Medical Equipment $0.00
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00
Copayment for Medicare-covered Lab Services $0.00

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00
Copayment for Medicare-covered Therapeutic Radiological Services $0.00
Copayment for Medicare-covered X-Ray Services $0.00
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $100.00
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $50.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 100

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit every year
Maximum Plan Benefit of $2000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Copayment for Periodontics $0.00
  • Maximum 1 visit every year
Maximum Plan Benefit of $2000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00
  • Maximum 2 Routine Eye Exams every year

Eyewear:
Coinsurance for Medicare-Covered Benefits 20%
Copayment for Contact Lenses $0.00
Copayment for Eyeglasses (lenses and frames) $0.00
Maximum Plan Benefit of $150.00 every year for all Non-Medicare covered eyewear

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 2 visits every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $499.00 to $799.00
  • Maximum 2 Hearing Aids every year
Copayment Structure: Up to two TruHearing-branded hearing aids every year (one per ear per year). Benefit is limited to TruHearing’s Advanced $499 and Premium $799 hearing aids, which come in various styles and colors. Premium hearing aids are available in rechargeable style options. Benefit is combined in- and out-of-network. You must see a TruHearing provider to use this benefit. Hearing aid purchase includes: • First year of follow-up provider visits • 60-day trial period • 3-year extended warranty • 80 batteries per aid for non-rechargeable models • Optional hearing aid rechargeability (Premium model only) Benefit does not include or cover any of the following: • Ear molds • Hearing aid accessories • Additional provider visits • Additional batteries, batteries when a rechargeable hearing aid is purchased • Hearing aids that are not TruHearing-branded hearing aids • Costs associated with loss & damage warranty claims Costs associated with excluded ite

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The Platinum Blue Complete Plan with Rx (Cost) plan offers the following prescription drug coverage, with an annual drug deductible of $480 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $480 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $9.00
    • Standard mail order $9.00
    Annual Drug Deductible $480 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $18.00
    • Standard mail order $18.00
    Annual Drug Deductible $480 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $18.00
    • Standard mail order $18.00