2009 BlueAdantage PPO Plan Options In-Network Benefits
2009 BlueAdantage PPO Plan Options In-Network Benefits
Covered Services |
Sapphire |
Diamond |
You Pay: |
You Pay |
|
Inpatient Hospital |
$250 copay per day for up to 5 days. $0 copay per day after 5 days. |
$0 copay per visit |
Office Visit |
$30 copay per primary care visit $30 copay per specialist visit |
$10 copay per primary care visit $10 copay per specialist visit |
Outpatient Services |
$250 copay per visit
|
$0 copay per visit |
Annual Physical |
$0 copay per visit |
$0 copay per visit |
Preventive Screenings |
$0 copay per visit |
$0 copay per visit |
Dental Services |
Not covered |
Plan pays up to $150 toward dental expenses annually |
Hearing Services |
Routine exams and Hearing aids not covered |
$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. |
$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 PPO plan for these cost sharing (d) amounts to apply and be received from network providers. Different deductibles, copays, coinsurance and out-of-pocket maximums (d) apply for services received from providers outside the plan’s network. 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 exclusion, please review the Evidence of Coverage. For full information on BlueAdvantage PPO 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, copay, coinsurance, formulary (d), pharmacy directory, and provider network may change on Jan. 1, 2010.
Medicare Products
BlueAdvantage PPO
Additional Information
A health plan with a Medicare contract.
H5884/H4979/H7917/S1030_W09_R4
<12/10/2009>
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