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Benefits
Benefits |
Basic |
Classic |
You Pay: |
You Pay: |
|
Out-of-Pocket Maximum |
$5,000 |
$2,500 |
Inpatient Hospital |
$215 copay per day for up to 5 days, $0 copay per day after 5 days |
$100 copay per day for up to 3 days, $0 copay per day after 3 days |
Doctor Office Visits |
$30 copay per primary care visit, $45 copay per specialist visit |
$10 copay per primary care visit, $25 copay per specialist visit |
Outpatient Services / Surgery |
$250 copay per visit |
$100 copay per visit |
Annual Physical |
No copay |
|
Emergency Care |
$50 copay (waived if admitted) |
|
Skilled Nursing Facility |
$125 for days 21-100 |
$0 for days 1-100 |
Home Health Care |
No copay |
|
Diagnostic Tests, X-rays and Lab Services |
No copay |
|
No copay |
||
Immunizations |
No copay |
|
Diabetic Supplies |
No copay |
|
Dental Services |
Not covered |
Plan pays up to $100 per year |
Hearing Services |
$30 copay for diagnostic exams per visit; Routine exams and hearing aids not covered |
$10 copay for routine and diagnostic exams per visit; Hearing aids not covered |
Vision Services |
$30 copay for diagnostic exams per visit |
$10 copay for routine and diagnostic exams per visit; Plan pays $100 toward eyewear annually |
Summary of Benefits |
||
Evidence of Coverage |
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*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 PFFS plan for these cost sharing 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 Medical-Only, 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.
A health plan with a Medicare contract.
H4979_W10_R2 CMS Approved 01042010
H4979_W10_R2 CMS Approved 01042010
© 2008 BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association. ® Registered marks of BlueCross BlueShield Association. BlueRx is a regional Medicare prescription drug plan provided by BlueCross and BlueShield of Alabama and BlueCross BlueShield of Tennessee, Independent Licensees of the BlueCross and BlueShield Association. Please see our Privacy Policy, guidelines for E-mail Correspondence, and other Legal Information for this site.
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