2014 Platinum Blue(SM) (Cost) - great value in a high quality medical plan

About the 2014 Platinum Blue plan

Platinum Blue, a Medicare-approved Cost plan from Blue Cross and Blue Shield of Minnesota, can help pay for your medical costs and provide additional benefits and services as well.

The Platinum Blue plan includes:

  • Access to a large provider network of doctors, clinics and hospitals (PDF) Flexible coverage that allows you to change among three plan options at any time  
  • The Silver&Fit® Exercise and Healthy Aging Program at no additional cost


Choose from three plan options:

  Platinum Blue Core
member pays:
Platinum Blue Choice
member pays:
Platinum Blue Complete
member pays:
Monthly plan premium $29 $74 $109
Deductible $0 $0 $0
Doctor's office visits 20% coinsurance $15 copay $0
Inpatient hospital care $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
Emergency care $50 copay $50 copay $0
Annual plan out-of-pocket maximum $5,000 $3,000 $3,000


Prescription drug coverage

Platinum Blue does not include coverage for Part D prescription drugs and can be paired with a stand-alone plan. Visit MedicareBlue(SM) Rx (PDP) ExternalLink to learn about prescription drug coverage options.


More plan information

Benefits overview (PDF)

Annual Notice of Changes - Platinum Blue Core

Annual Notice of Changes - Platinum Blue Choice

Annual Notice of Changes - Platinum Blue Complete

Plan ratings (PDF)

Provider directory (PDF)

Silver&Fit® Exercise and Healthy Aging Program (PDF)

Summary of Benefits (PDF)

Get Acrobat Reader ExternalLink


Platinum Blue is a Cost plan with a Medicare contract. Enrollment in Platinum Blue depends on contract renewal. The benefit information provided is a brief summary not a complete description of benefits. For more information contact the plan. Limitations, copayments and restrictions may apply. You must continue to pay your Medicare Part B premium. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You can also view additional details in the benefits overview (PDF) or the Summary of Benefits (PDF) .

Blue Cross® and Blue Shield® and the Cross and Shield Symbols are registered marks of the Blue Cross and BlueShield Association, an association of independent Blue Cross and/or Blue Shield Plans.

The Silver&Fit program is a product of 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.

Last updated March 5, 2014
H2461_020614_N07 CMS Approved 03/05/2014

Networks, discounts and travel benefits for 2014 Platinum Blue

Find a doctor in the network

See any provider in the Platinum Blue network (PDF), no referral needed. You can also see doctors outside the network for Medicare-covered services but you may pay more for those services.

Discounts on health and wellness

  • With your  Silver&Fit® membership, ExternalLink you have access to fitness equipment, classes and health tools, or home fitness kits geared to older adults
  • Save on eyewear and hearing aids
  • Find answers to your medical questions using our health and wellness online resources. You’ll get access to health calculators, quizzes, exclusive articles and more.

Travel benefits

Travel throughout the United States for up to nine months and receive plan benefits from any provider that accepts Medicare. No referrals needed. You’ll also receive emergency care nationwide.


The benefit information provided is a brief summary not a complete description of benefits. For more information contact the plan. Limitations, copayments and restrictions may apply. You must continue to pay your Medicare Part B premium. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year.

Last updated October 1, 2013
H2461_091913_N05 CMS Approved 10/22/2013

Enroll today in 2014 Platinum Blue

Eligibility
You must be a resident of Minnesota to enroll in Platinum Blue. You must also be entitled to Medicare Part A and enrolled in Medicare Part B, or enrolled in Part B only. You may not be eligible 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 or Blue Plus plan.

Generally, you may enroll in a Cost plan at any time during the year. However, if you are a member of a Medicare Advantage plan, you may not be able to enroll if you are locked in to your current plan.

 

Choose how you’d like to enroll:

Enroll online

Select “Medicare Cost Plans” (on the first screen) to see Platinum Blue plans. Be sure to review the Summary of Benefits when prompted.

Enroll online

Download enrollment materials

1. Review this information:
Benefits overview (PDF)
Plan ratings (PDF)
Summary of Benefits (PDF)

2. Complete these forms:
Insurance suitability form (PDF) – This form is required. It has three sections. Please review, sign and date each section that applies to you. Keep a copy for your records. You do not need to mail it to us.

Platinum Blue enrollment form (PDF)

Pay-O-Matic form (PDF) – This form is optional. It is a convenient way to pay your premium. If you choose this option, return this completed form with your enrollment form to the address below.

3. Mail your form(s) to:
Platinum Blue
Blue Cross and Blue Shield of Minnesota
P.O. Box 64024
St. Paul, MN 55164-0024

4. Relax! We’ll be in touch.
We may call you after we receive your enrollment form. The purpose of the call is to help you understand how the plan works and answer your questions. If you get a call from us and have questions, please call 1-888-329-5302 (TTY users call 711), Monday through Friday, 9 a.m. to 5 p.m., Central Time.

You will also get at least two letters from us. The first will let you know that we received your enrollment request. The second will confirm whether CMS has approved your enrollment in Platinum Blue.

Enroll by phone

8 a.m. to 8 p.m. Central Time, daily
 

Request an enrollment kit

It will include all the forms you need to enroll. Order a kit ExternalLink

 

If you’re interested in prescription drug coverage, learn more about MedicareBlue(SM) Rx (PDP). ExternalLink

Last updated October 1, 2013
H2461_091913_N05 CMS Approved 10/22/2013

Member resources for 2014 Platinum Blue

Discounts and special programs

Complementary care and products
Enjoy discounts (up to 25 percent) on acupuncture and massage therapy at ChooseHealthy.com. ExternalLink  You can also get discounts on health and wellness products from Edgepark Medical Supplies ExternalLink  and
Rotech Healthcare. ExternalLink

Health Guides
When you have questions about your benefits, finding a provider or choosing the right type of care, our specially trained health guides will help. Sign in or register for myBlueCross to learn more.

Hearing aids
Visit any Beltone Hearing Aid Center to receive a 25 percent discount off the price of any hearing aid.
Find a location near you (PDF)*

myBlueCross online member center
The myBlueCross online member center has tools and information to help you manage your health and your health plan. By signing in to this secure site, you can search for a doctor, see the status of your recent claims, compare provider cost and quality information, and much more. Sign in or register for myBlueCross to learn more.

Silver&Fit® Exercise and Healthy Aging Program
Your  Silver&Fit membership ExternalLink gives you access to:

  • Exercise equipment weights and specially designed fitness classes at facilities participating with Silver&Fit (where available)
  • Fitness advisors at your facility to help you get the most out of your membership
  • Tools to help you track your fitness goals and achievements
  • Choice of home exercise kits instead of membership with a facility
  • Healthy aging classes online or via mail

Stop-Smoking Support
Take advantage of this proven, successful program. Trained phone counselors and support materials can help you quit. Sign in or register for myBlueCross to learn more.

Vision and eyewear
Visit a network optician (PDF)* and receive a 20 percent discount on frames, lenses and contacts not covered under the medical portion of your benefits, plus get LASIK discounts. ExternalLink

Weight Watchers
Save $10 on a three-month membership to Weight Watchers ExternalLink  online.

*Providers may join or leave the network at any time. To find out if a provider is still in the network, call customer service at the number on the back of your member ID card.


Complaints & appeals

For a complete description of the complaint, coverage determination (including exceptions) and appeals process, see Chapter 7 of your Evidence of Coverage: Core plan (PDF), Choice plan (PDF) or Complete plan (PDF).

You can also call member services or send a letter to:
Blue Cross and Blue Shield of Minnesota
Platinum Blue – Grievances
P.O. Box 64560
St. Paul, MN 55164-0560


How to find more information

For more information about your rights and responsibilities, the service area, premiums and cost-sharing, out of network coverage and information about filing a grievance, coverage determination or appeal, review the Evidence of Coverage: Core plan (PDF), Choice plan (PDF) or Complete plan (PDF).

You can also call or write to us:
1-866-340-8654
8 a.m. to 8 p.m. Central Time, daily
TTY users call 711

Platinum Blue
P.O. Box 64024
St. Paul, MN 55164-0024

Or visit Medicare.gov ExternalLink or call toll-free
1-800-MEDICARE (1-800-633-4227)
24 hours a day, 7 days a week
TTY users call 1-877-486-2048


Helpful resources and materials

Discharge Preparation Checklist (PDF) – What to do before you leave the hospital

Evidence of Coverage for Core plan (PDF)
(see Chapter 6 for rights and responsibilities; see Chapter 7 for grievance, coverage determination and appeals information)

Evidence of Coverage for Choice plan (PDF)
(see Chapter 6 for rights and responsibilities; see Chapter 7 for grievance, coverage determination and appeals information)

Evidence of Coverage for Complete plan (PDF)
(see Chapter 6 for rights and responsibilities; see Chapter 7 for grievance, coverage determination and appeals information)

Medicare Ombudsman ExternalLink

Personal Health Record ExternalLink – Prepare for your next medical visit

Privacy notice (PDF)


Forms and coverage information

Appoint a representative ExternalLink

Medicare complaint form ExternalLink

Hearing aid and eyewear claim form (PDF)

Get Acrobat Reader ExternalLink

 

Blue Cross® and Blue Shield® and the Cross and Shield Symbols are registered marks of the Blue Cross and BlueShield Association, an association of independent Blue Cross and/or Blue Shield Plans.

The Silver&Fit program is a product of 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 trademarks of ASH and used with permission herein.

Weight Watchers is the registered trademark of Weight Watchers International, Inc. and is used under license.

Last updated December 26, 2013
H2461_122413_N02 CMS Approved 12/29/2013