Platinum Blue Core Plan with Rx (Cost)
Platinum Blue Core Plan with Rx (Cost) H2461-008 Plan Details
Platinum Blue Core Plan with Rx (Cost) is a Medicare Advantage (Medicare Part C) plan offered by Aware Integrated, Inc..
Plan ID: H2461-008.
$43.20
Monthly Premium
Platinum Blue Core Plan with Rx (Cost) is a Medicare Advantage (Medicare Part C) plan offered by Aware Integrated, Inc..
Plan ID: H2461-008.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $480 |
| Out of Pocket Max |
In-Network: $6000 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 $20.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $20.00 Coinsurance for Physician Specialist Office Visit 20% 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 $600.00 |
| Urgent Care | Copayment for Urgent Care $65.00 |
| Emergency Room Visit | Copayment for Emergency Care $90.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $90.00 Coinsurance for Worldwide Emergency Transportation 20% |
| Ambulance Transportation | In-Network: Ground Ambulance: Coinsurance for Ground Ambulance Services 20% Air Ambulance: Coinsurance for Air Ambulance Services 20% |
Health Care Services and Medical Supplies
Platinum Blue Core 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 $20.00 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 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% 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: Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20% Copayment for Medicare-covered Lab Services $0.00 Outpatient Diag/Therapeutic Rad Services: Coinsurance for Medicare-covered Diagnostic Radiological Services 20% Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $60.00 |
| 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 $600.00 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 20% Outpatient Observation Services: Coinsurance for Medicare Covered Observation Services 20% Ambulatory Surgical Center Services: Coinsurance for Ambulatory Surgical Center Services 20% |
| Outpatient Substance Abuse Care | In-Network: Coinsurance for Medicare-covered Individual Sessions 20% Coinsurance for Medicare-covered Group Sessions 20% |
| 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 $25.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $50.00 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $188.00 per day for days 21 to 100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Comprehensive Dental: Coinsurance for Medicare-covered Benefits 20% |
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 Eyewear: Coinsurance for Medicare-Covered Benefits 20% |
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
Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00
|
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:
Yearly "Wellness" visit |
