Frequently Asked Questions

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If I purchase this plan, am I losing my Medicare coverage?

No. Medicare Advantage plans are part of the Medicare program. These plans are only administered by private insurance companies under contract with the Medicare program.

Why do I have to pay my Medicare Part B premium if this replaces my Medicare and Medicare isn’t paying my claims?

BlueCross BlueShield of Tennessee and other Medicare Advantage insurance companies have a contract with Medicare to provide your Medicare Parts A and B coverage. As part of this contract, the plan receives payments from Medicare to cover the cost of your benefits. Your Medicare Part B premium, along with the premium you pay for the plan, make up the total premium needed to provide your Medicare Advantage benefits.

Will I still show my Medicare card when receiving health care services?

No, if you enroll in this plan you will show your BlueAdvantage PPO card each time you receive health care services. However you should keep your Medicare Card in a safe place. You will need to show your Medicare card if you receive hospice care.

Does BlueAdvantage PPO cover the same type of services as Original Medicare?

Yes, BlueAdvantage PPO will cover the same types of services that Original Medicare covers, plus some additional services not covered by Original Medicare. Please see the Summary of Benefits for a comparison of covered services. Hospice care is still covered under Original Medicare and you should show your Medicare card for hospice care.

Once I select a Medicare Advantage plan, can I change plans later?

Yes, during Medicare-specified enrollment periods.  Each year you can start over with a different plan during the Annual Coordinated Election Period, November 15 through December 31 for coverage beginning January 1 of the following year. Additionally, you have the opportunity to change one time during Open Enrollment, January 1 to March 31.  Please be aware that your options during the Open Enrollment Period are limited based on the type of plan you are enrolled in the year prior to January 1. Once the Open Enrollment Period ends on March 31, you may not make any more plan changes until the next Annual Coordinated Election Period, unless you qualify for a Special Enrollment Period. Please see Eligibility and Enrollment Periods for more information.

Is there a waiting period before benefits will be paid on pre-existing medical conditions?

No, there isn’t a pre-existing condition (d) waiting period. 

Do I have to choose a Primary Care Physician?

No. You are not required to select one doctor to receive general care or serve as a gatekeeper for your medical care.

Do I need a referral to see a specialist?

No. You may see any specialist physician you like, without getting a referral. Remember, you may pay more if you choose a specialist outside of the BlueAdvantage PPO provider network.

Do I have to use providers in the BlueAdvantage PPO for my medical care?

No, but if you use providers outside of the network, you will pay more. Separate copays, coinsurance and out-of-pocket maximums (d) apply to services received from out-of-network providers. 

What happens if I go to an out-of-network provider in an emergency situation? 

In the case of an emergency, you should always seek medical care from the closest available provider. You will receive in-network benefits for emergency care you receive even if the provider is not in the BlueAdvantage PPO network.

Will out-of-state doctors accept my BlueAdvantage PPO plan if I’m traveling?

You may get care when you are outside the service area. In most cases you may need to pay higher cost sharing for routine care from non-network providers, but you won’t pay extra in a medical emergency. If you have questions about your medical costs when you travel, please call customer service number on the back of your BlueAdvantage PPO ID card.

If you are traveling in New York or South Carolina, we have a Visitor/Traveler program agreement with the Medicare Advantage Local PPO offered by these participating BlueCross BlueShield Plans.  Through the Visitor/Traveler program, you will pay the same in-network cost sharing amount you would pay if you received covered benefits from in-network providers in BlueCross BlueShield of Tennessee’s service area.

Your enrollment materials will identify the counties in those states in which the Visitor/Travel program is available.  In addition, members may contact us or call 1-800-810-BLUE to find out what providers participate in this program.  A list of providers will also be available on the . BlueCross BlueShield Doctor Hospital Finder at BCBS.com (off site)

What happens to my coverage if BlueCross BlueShield of Tennessee leaves the Medicare program? Can I go back to Original Medicare Part  A and Part B?

All health plans with Medicare contracts agree to stay with the Medicare program for a full year. Coverage from a particular plan beyond the current year is not guaranteed. Each year plans can decide if they wish to continue for another year. The Centers of Medicare & Medicaid Services can also decide not to renew a plan’s contract. If a plan leaves the Medicare program, you will not lose Medicare coverage. You will receive notification 90 days in advance along with information about your other Medicare coverage options. 

Will BlueAdvantage PPO monthly premiums or benefits change next year? 

The BlueAdvantage PPO contract is renewed annually with Medicare. The premiums, benefits, copays and coinsurance amounts can change annually. Members will receive an Annual Notice of Change in the mail prior to Nov. 15 for changes effective the following Jan. 1.

Also, remember everyone has the opportunity to change plans each year during the Annual Coordinated Election Period (Nov. 15 to Dec. 31). 

Can I enroll in another Medicare Part D plan with BlueAdvantage PPO Sapphire or Diamond?

No. You must get your prescription drug benefits through your BlueAdvantage PPO plan.

What is the difference between a preferred and non-preferred brand-name drug?

Preferred brand-name drugs are therapeutically sound, cost-effective brand-name drugs that we encourage members to use within the therapeutic drug classes listed in the formulary. Using preferred drugs helps you save money. You will pay a lower, tier two copay for formulary preferred brand-name drugs.  Non-preferred brand-name drugs are drugs that are still covered under your plan, but at a higher, tier three copay.

If the drug is available in generic, do I have to take the generic?

If a brand drug has a generic equivalent available, and only the generic drug is on the formulary, you can purchase the brand drug, but you will be responsible for 100 percent of the cost. These costs will not count toward your $2,700 Initial Coverage Limit (d) or the $4,350 Catastrophic Coverage Threshold (d). Please talk to your doctor about switching to generics if a generic is available and appropriate for your treatment.

How do I file my prescription drug claims?

To receive benefits for prescription drugs, you must purchase your drugs at a pharmacy that participates in the BlueAdvantage PPO pharmacy network. These participating network pharmacies will submit your claims electronically and you will only pay the applicable copay amounts. If you are in the Coverage Gap (d) phase, you still need to use a participating network pharmacy and show your BlueAdvantage PPO ID card to make sure that you receive the network discount price. Showing your BlueAdvantage PPO ID card will also ensure that your out-of-pockets costs count toward your $4,350 catastrophic coverage threshold.

Are all of my prescription drugs covered under BlueAdvantage PPO?

BlueAdvantage PPO uses a formulary. A formulary is a list of drugs selected to meet patient needs. Your drug must be listed on the formulary for it to be covered.

Some drugs that may be listed on the BlueAdvantage PPO formulary may be covered under the Medicare Part B portion of your coverage depending on the reason you are taking the drug and the setting in which you receive it. This means that your Part D copays and benefits will not apply to these drugs, even though they may be listed in the formulary. Examples of the types of drugs that may be subject to Part B coverage include:

• Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.

• Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.

• Erythropoietin (Epoetin alpha or Epogen®): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.

• Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.

• Injectable Drugs: Most injectable drugs are administered during a physician’s service.

• Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare or paid for by a private insurance company that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility.

• Some Oral Cancer Drugs: If the same drug is available in injectable form.

• Oral Anti-Nausea Drugs: If the drug is part of an anti-cancer chemotherapeutic regimen.

• Inhalation and infusion drugs provided through Durable Medical Equipment supplier.

These Part B costs will not count toward your $2,700 Initial Coverage Limit or the $4,350 Catastrophic Coverage Threshold.