Blue Cross Blue Shield Advantage Plans of Minnesota

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1. MN
2. Blue Cross and Blue Shield of Minnesota
3. Plan

Blue Cross Medicare Advantage Complete (PPO)

Medicare Plan Details (2022 Plan)

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Monthly Premium

by Blue Cross and Blue Shield of Minnesota

Additional Coverage

Hearing Vision Dental

Overall Government Star Rating

4.5

out of 5 stars

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Ready to Enroll Online?

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Plan Type

Medicare Advantage (Part C) with Prescription Drug (Part D)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D

Health Portion of Premium

Health Plan Max Out-of-Pocket

$5,100 In and Out-of-network
$2,900 In-network

Nationwide Coverage included

Hearing Coverage included

Doctor Services

Primary doctor visit

In-network: $0-20 copay per visit
Out-of-network: 45% coinsurance per visit

Specialist visit

In-network: $20 copay per visit
Out-of-network: 45% coinsurance per visit

Tests, labs, & imaging

Diagnostic tests & procedures

In-network: $0 copay
Out-of-network: 45% coinsurance

Lab services

In-network: $0 copay
Out-of-network: $0 copay

Diagnostic radiology services (like MRI)

In-network: $0 copay
Out-of-network: 45% coinsurance

Outpatient x-rays

In-network: $0 copay
Out-of-network: 45% coinsurance

Emergency care

$90 copay per visit (always covered)

Urgent care

$25 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage

In-network: $150 per stay
Out-of-network: 45% per stay

Outpatient hospital coverage

In-network: $0-100 copay per visit
Out-of-network: 45% coinsurance per visit

Skilled nursing facility

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$188 per day for days 21 through 100
Out-of-network: 45% per stay

Preventive services

Preventive services

In-network: $0 copay
Out-of-network: 45% coinsurance

Ambulance

Ground ambulance

In-network: $50 copay
Out-of-network: $50 copay

Therapy services

Occupational therapy visit

In-network: $20 copay
Out-of-network: 45% coinsurance

Physical therapy & speech & language therapy visit

In-network: $20 copay
Out-of-network: 45% coinsurance

Mental health services

Outpatient group therapy with a psychiatrist

In-network: $20 copay
Out-of-network: 45% coinsurance

Outpatient individual therapy with a psychiatrist

In-network: $20 copay
Out-of-network: 45% coinsurance

Outpatient group therapy visit

In-network: $20 copay
Out-of-network: 45% coinsurance

Outpatient individual therapy visit

In-network: $20 copay
Out-of-network: 45% coinsurance

Opioid treatment services

Opioid treatment services

Other services

Durable medical equipment (like wheelchairs & oxygen)

In-network: 15% coinsurance per item
Out-of-network: 45% coinsurance per item

Prosthetics (like braces, artificial limbs)

In-network: 15% coinsurance per item
Out-of-network: 45% coinsurance per item

Diabetes supplies

In-network: $0 copay
Out-of-network: 45% coinsurance per item

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

Tiers	Initial coverage phase	Gap coverage phase	Catastrophic coverage phase
Preferred Generic	$0.00 copay	Generic drugs : 25% Brand-name drugs : 25%	Generic drugs : $3.95 copay or 5% (whichever costs more) Brand-name drugs : $9.85 copay or 5% (whichever costs more)
Generic	$9.00 copay
Preferred Brand	$47.00 copay
Non-Preferred Drug	45%
Specialty Tier	33%

Part B Drugs

Chemotherapy drugs

In-network: 20% coinsurance
Out-of-network: 45% coinsurance

Other Part B drugs

In-network: 20% coinsurance
Out-of-network: 45% coinsurance

Hearing

Hearing exam

In-network: $0 copay
Out-of-network: 45% coinsurance

Fitting/evaluation

In-network: $0 copay
Out-of-network: $0 copay or 45% coinsurance

Hearing aids - All types

In-network: $499-799 copay
Out-of-network: $499-799 copay

Preventive Dental

Oral exam

In-network: $0 copay
Out-of-network: $0 copay

Cleaning

In-network: $0 copay
Out-of-network: $0 copay

Fluoride treatment

In-network: $0 copay
Out-of-network: $0 copay

Dental x-rays

In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Restorative services

In-network: 30% coinsurance
Out-of-network: 0-50% coinsurance

Endodontics

In-network: 50% coinsurance
Out-of-network: 0-50% coinsurance

Periodontics

In-network: 0-50% coinsurance
Out-of-network: 0-50% coinsurance

Extractions

In-network: 50% coinsurance
Out-of-network: 0-50% coinsurance

Prosthodontics, other oral/maxillofacial surgery, other services

In-network: 50% coinsurance
Out-of-network: 0-50% coinsurance

Vision

Routine eye exam

In-network: $0 copay
Out-of-network: 45% coinsurance

Contact lenses

In-network: $0 copay
Out-of-network: $0 copay

Eyeglasses (frames & lenses)

In-network: $0 copay
Out-of-network: $0 copay

Eyeglass frames (only)

In-network: $0 copay
Out-of-network: $0 copay

Eyeglass lenses (only)

In-network: $0 copay
Out-of-network: $0 copay

Other benefits

Over the counter drug benefits

Home and bathroom safety devices

Summary rating of health plan quality

Staying healthy: screenings, tests, & vaccines

Managing chronic (long term) conditions

Member experience with health plan

Member complaints & changes in the health plan's performance

Health plan customer service

Summary rating of drug plan quality

Drug plan customer service

Member complaints & changes in the drug plan's performance

Member experience with the drug plan

Drug safety & accuracy of drug pricing

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No obligation to enroll. Find your plan online or speak with a licensed insurance agent to get help signing up for the right plan for you! Plan availability depends on your location. Licensed agents may not be able to provide assistance for all plans shown on this site.

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Source: https://healthplanradar.com/medicare_plans/mn/blue-cross-and-blue-shield-of-minnesota/H5959-011-0/blue-cross-medicare-advantage-complete-ppo

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