Benefits

2009 BlueAdvantage PFFS with Prescription Drug Plan Options

Covered Services	Silver	Gold	Platinum
Covered Services	You Pay:	You Pay:	You Pay:
Inpatient Hospital	$250 copay per day for up to 5 days. $0 copay per day after 5 days.	$250 copay per admittance	$0 copay per visit
Office Visit	$30 copay per visit	$20 copay per visit	$10 per visit
Outpatient Services	$250 copay per visit	$100 copay per visit	$0 copay per visit
Annual Physical	$0 copay per visit	$0 copay per visit	$0 copay per visit
Preventive Screenings	$0 copay per visit	$0 copay per visit	$0 copay per visit
Dental Services	Not covered	Plan pays up to $150 toward dental expenses annually	Plan pays up to $150 toward dental expenses annually
Hearing Services	Routine exams and Hearing aids not covered	$20 copay for routine and diagnostic exams per visit. Plan pays $200 toward hearing aids every 2 years	$10 copay for routine and diagnostic exams per visit. Plan pays $200 toward hearing aids every 2 years
Vision Services	Routine exams and eyewear not covered.	$20 copay for routine and diagnostic exams per visit. Plan pays $100 toward eyewear annually	$10 copay for routine and diagnostic exams per visit. Plan pays $100 toward eyewear annually

*You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third-party.

All services must be covered by Medicare or the BlueAdvantage PFFS plan for these cost sharing (d) amounts to apply. For a complete list of benefits as compared to Original Medicare, please see the Summary of Benefits. For detailed information on this plan and its major limitations or exclusions, please review the Evidence of Coverage. For full information on BlueAdvantage PFFS please contact us.

BlueCross BlueShield of Tennessee’s Medicare contract is renewed annually. The availability of coverage beyond the end of this contract year is not guaranteed. Benefits, premiums, copays, coinsurance, formulary (d) and pharmacy directory may change on Jan. 1, 2010.

Medicare Products

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BlueAdvantage PFFS with Prescription Drug Coverage

Additional Information

A health plan with a Medicare contract.
H5884/H4979/H7917/S1030_W09_R4
<12/10/2009>

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