BCBST Medicare Products

Medical Benefits

Benefits	Sapphire	Ruby	Diamond
Benefits	*You Pay:*	*You Pay:*	*You Pay:*
Out-of-Pocket Maximum	$4,000	$3,400	$2,500
Inpatient Hospital	$1,000 inpatient deductible	$100 copay per day for up to 7 days, $0 copay per day after 7 days	$100 copay per day for up to 3 days, $0 copay per day after 3 days
Doctor Office Visits	$20 copay per primary care visit, $35 copay per specialist visit	$20 copay per primary care visit, $35 copay per specialist visit	$10 copay per primary care visit, $25 copay per specialist visit
Outpatient Services / Surgery	$300 copay per visit	$200 copay per visit	$100 copay per visit
Annual Physical	$0 copay per visit	$0 copay per visit	$0 copay per visit
Emergency Care	$50 copay (waived if admitted)
Skilled Nursing Facility	$125 for days 21-100	$150 for days 21-100	$0 for days 1-100
Home Health Care	No copay
Diagnostic Tests, X-rays and Lab Services	No copay
Preventive Screenings	No copay
Immunizations	No copay
Diabetic Supplies	No copay
Dental Services	Not covered	Plan pays up to $100 per year	Plan pays up to $100 per year
Hearing Services	$35 copay for diagnostic exams per visit; routine exams and hearing aids not covered	$20 copay for routine and diagnostic exams per visit; hearing aids not covered	$10 copay for routine and diagnostic exams per visit; hearing aids not covered
Vision Services	$35 copay for diagnostic exams per visit; routine exams and eyewear not covered	$20 copay for diagnostic exams per visit; routine exams and eyewear not covered	$10 copay for routine and diagnostic exams per visit; plan pays $100 toward eyewear every other year
Summary of Benefits	Sapphire	Ruby	Diamond
Evidence of Coverage	Sapphire	Ruby	Diamond

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

All services must be covered by Medicare or the BlueAdvantage PPO plan and received from network providers for these cost sharing amounts to apply. Higher deductibles, copays, coinsurance and out-of-pocket maximums 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 (Sapphire/Ruby/Diamond). For detailed information on this plan and its major limitations or exclusions, please review the Evidence of Coverage (Sapphire/Ruby/Diamond). For full information on BlueAdvantage PPO please contact us.

For full information on BlueCross BlueShield of Tennessee benefits, call our Customer Service Department at 1-866-210-1522, 8 am to 9 pm, Eastern Time, 7 days a week. TTY users should call, 1-877-664-6422. From March 1 to September 30, you may be required to leave a voice mail on weekends and holidays. Calls will be returned within one business day.

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 and coinsurance amounts may change on January 1, 2011.

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BlueAdvantage PPO

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A health plan with a Medicare contract.
H7917_W10_R2 CMS Approved 01042010

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