In most cases, Medicare is a federal health insurance program for people 65 years old or over and for certain disabled people under 65 years of age. You are automatically enrolled in Medicare hospital insurance (Part A) when you apply for Social Security benefits – usually upon reaching 65 years of age. Part A covers inpatient care in a hospital or a limited stay in a skilled nursing facility. Part B covers physician and outpatient hospital services. The premium you pay for Part B is deducted from your Social Security benefits.

Medicare pays for many healthcare services and supplies, but it doesn't cover all of your healthcare costs. For example, you pay a deductible for each hospital stay and coinsurance anytime you use the services of a physician or surgeon. Also, drug coverage is limited. Because Medicare rarely pays the full cost of covered services, you may want to consider a Medicare Advantage or Medicare Supplement plan.

A Medicare Advantage Plan is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.

If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D); these plans are known as Medicare Advantage Prescription Drug Plans (MA-PD).  

Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan network for non‑emergency or non-urgent care). These rules can change each year.

Medicare Advantage Plans offered by BlueCross BlueShield of Tennessee are known as BlueAdvantage Plans and include:

• Preferred Provider Organization (PPO) Plans
• Private Fee-for-Service (PFFS) Plans (available in limited counties)

With a Medicare Advantage PPO, you can see any Medicare participating doctor you want. However, if you use a doctor who participates in the network, you get a better benefit and lower copayment/coinsurance than if you visit a non-network doctor. Plus, referrals aren't needed, and you don't have to see a primary care physician first. In addition to prescription drug benefits, Medicare Advantage PPOs may offer other benefits such as dental, vision, and nutritional supplements. If you select a Medicare Advantage PPO, it is an alternative to your Medicare coverage. However, you can return to Medicare during Medicare defined enrollment times.

Find the BlueCross BlueShield of Tennessee Medicare Advantage Plan that is right for you. 

PFFS plans feature limits on out-of-pocket expenses, coverage for emergency and urgent care, and in some cases, a prescription drug benefit. If you select a PFFS plan, it is an alternative to your Medicare coverage. However, you can return to Medicare down the road if you wish.

Find the BlueCross BlueShield of Tennessee Medicare Advantage Plan that is right for you.

Medicare prescription drug coverage is insurance that covers both brand-name and generic prescription drugs at participating pharmacies in your area. Medicare prescription drug coverage provides protection for people who have very high drug costs or from unexpected prescription drug bills in the future.

Find the BlueCross BlueShield of Tennessee Prescription Drug Plan that is right for you.

A Medicare Supplement insurance plan helps cover the costs that are left unpaid after Original Medicare pays its portion of your healthcare expenses.  Unlike a Medicare Advantage plan, which is an alternative to your Medicare Parts A and B benefits, a Medicare Supplement plan is purchased in addition to your Medicare Parts A and B benefits.

Medicare Supplement policies are available from private insurance companies. While the costs of these policies may vary, individual insurance companies must provide the same standardized benefits as outlined by law.

Medicare Supplement policies are standardized into 10 plans - labeled "A" through "N", each with its own set of benefits. Plan A covers the most basic benefits. These basic benefits are also covered in each of the remaining Medicare Supplement plans - B through N (except Plans K, L, and N require beneficiaries to pay a portion of Part B coinsurance or co-payments.)   Plans B through N provide additional coverage beyond the basics. BlueCross BlueShield of Tennessee offers plans A, D and F. The BlueCross BlueShield of Tennessee Medicare Supplement Plans are known as BlueElite.  

Find the BlueCross BlueShield of Tennessee Medicare Supplement Plan that is right for you. 

Look at the "Is Entitled To" section of your red, white, and blue Medicare card. If you have Part A, "HOSPITAL (PART A)" is printed on your card. If you have Part B, "MEDICAL (PART B)" is printed on your card.

No. Medicare Advantage plans like BlueAdvantage are part of the Medicare program and provide Medicare coverage. These plans are administered by private insurance companies under contract with the Medicare program.

Yes. BlueAdvantage covers 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 Original Medicare Card for hospice care.

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

No. If you enroll in this plan, you will show your BlueAdvantage card each time you receive health care services. However, you should keep your Medicare card in a safe place in the event that you may need it for Hospice care.

No. There isn't a pre-existing condition waiting period for BlueAdvantage members. There may be underwriting requirement for BlueElite (Medicare Supplement) members.

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

No. You are free to see any specialist you like.

Beneficiaries can disenroll from, switch, or enroll into an MA plan or Part D plan during the Annual Election Period (AEP). AEP is October 15 to December 7.

The Annual Disenrollment Period (ADP) is January 1 to February 14. During this time beneficiaries can disenroll from a Medicare Advantage plan and return to Original Medicare. The ADP does not allow people in an MA plan to switch to another MA plan or people in Original Medicare to join an MA plan. Those beneficiaries who want to disenroll from an MA-PD plan and return to Original Medicare during the ADP starting 2011 will have a Special Election Period (SEP) to join a stand-alone Part D plan.

All health plans with Medicare contracts agree to stay with the Medicare program for a full year, but 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 and Medicaid Services, which administers Medicare and other programs under the umbrella of the U.S. Department of Health & Human 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.

The BlueAdvantage and BlueRx contracts are 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 by September 30 for changes effective the following January 1.

In 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.

BlueAdvantage Members:

You may choose CVS Caremark or Walgreens for your mail-order service. If you have questions or need more information, feel free to contact the pharmacy at the number listed below:

Call CVS Caremark at 1-866-249-6167
TTY/TDD users should call 1-866-236-1069
24 hours a day, 7 days a week

Call Walgreens at 1-800-489-2197
TTY/TDD users should call 1-800-925-0178
Monday-Friday, 8 am to 10 pm EST
Saturday and Sunday, 8 am to 5 pm EST

A formulary is a list of covered drugs provided by the plan. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other coverage rules are followed. For certain prescription drugs, we have additional requirements for coverage or limits on our coverage.

The drugs on the formulary are selected by our plan with the help of a team of health care providers. We select the prescription therapies believed to be a necessary part of a quality treatment program. Both brand-name drugs and generic drugs are included on the formulary. A generic drug has the same active ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs.

You may call Customer Service to find out if your drug is on the formulary or to request a copy of our formulary. You may also get updated information about the drugs covered by us by visiting our Web site at bcbst-medicare.com.

Drugs on our formulary are organized into different drug tiers, or groups of different drug types. Your coinsurance/co-payment depends on which drug tier your drug is in.

If your prescription isn’t listed on the formulary, you should first contact Customer Service to be sure it isn’t covered. If Customer Service confirms that we don’t cover your drug, you have three options:

1. You may ask your doctor if you can switch to another drug that is covered by us. If you would like to give your doctor a list of covered drugs that are used to treat similar medical conditions, please contact Customer Service or go to our Web site.


2. You may ask us to make an exception (which is a type of coverage determination) to cover your drug. See your Evidence of Coverage to learn more about how to request an exception.


3. You can pay out-of-pocket for the drug and request that the plan reimburse you by requesting an exception. This doesn’t obligate the plan to reimburse you if the exception request isn’t approved. If the exception isn’t approved, you may appeal the plan’s denial. Please see your Evidence of Coverage for more information on how to request an appeal.

In some cases, we will contact you if you are taking a drug that isn’t on our formulary. We can give you the names of covered drugs that also are used to treat your condition so you can ask your doctor if any of these drugs are an option for your treatment.

A network pharmacy is a pharmacy that has a contract with us to provide your covered prescription drug. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. Once you go to one, you aren't required to continue going to the same pharmacy to fill your prescription; you may go to any of our network pharmacies.

Preferred drugs are therapeutically sound, cost-effective drugs that we encourage members to use. Using preferred brand-name drugs helps you save money. You will pay a lower copay for preferred brand-name drugs. Non-preferred brand-name drugs are drugs that are still covered under your plan, but at a higher copay.

If a brand-name drug has a generic equivalent available, and only the generic drug is on the formulary, you can purchase the brand-name drug, but you will be responsible for the total cost. These costs will not count toward your initial coverage limit or the catastrophic coverage threshold. Please talk to your doctor about switching to generics if a generic is available and appropriate for your treatment.

To receive benefits for prescription drugs, you must purchase your drugs at a pharmacy that participates in the BlueAdvantage/BlueRx 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 phase, you still need to use a participating network pharmacy. Show your BlueCross BlueShield of Tennessee ID card to make sure that you receive the network discount price. Showing your ID will also ensure that your out-of-pockets costs count toward your catastrophic coverage threshold.

BlueAdvantage and BlueRx use a formulary, which 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 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 a doctor’s 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 incident to a physician’s service


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


• 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 a durable medical equipment supplier

These Part B costs will not count toward your initial coverage limit or the catastrophic coverage threshold.

The program is designed to cover drugs which are used to treat chronic conditions and are taken for a period of 30 days or longer.

BlueRx Members:

Your mail order service is provided through PrimeMail. To learn more call PrimeMail at:

1-800-731-3588
TTY users call 711
24 hours a day, 7 days a week

BlueAdvantage Members:

You may choose CVS Caremark or Walgreens for your mail-order service. If you have questions or need more information, feel free to contact the pharmacy at the number listed below:

Call CVS Caremark at 1-866-249-6167
TTY/TDD users should call 1-866-236-1069
24 hours a day, 7 days a week

Call Walgreens at 1-800-489-2197
TTY/TDD users should call 1-800-925-0178
Monday-Friday, 8 am to 10 pm EST
Saturday and Sunday, 8 am to 5 pm EST

Your prescriptions will be delivered to you, postage paid by the U.S. Mail or other carrier, within approximately 14 days from receipt of the order. Prescriptions can be shipped via overnight carrier for an additional charge.

That depends on you and your doctor. If you wish to obtain a brand name drug when a generic is available, your doctor must write "dispense as written" or "brand necessary" on the prescription. Generic drugs are equal in effectiveness and safety to brand name drugs. They contain the same active ingredients, have the same degree of purity, the same potency and the same concentration as their brand name counterparts. Yet, generic drugs generally offer savings of greater than 50 percent when compared to the brand name products.

In general, Medigap policies don’t cover any costs other than your cost sharing for Parts A and B, like deductibles, co-payments, and co-insurance. For example, they do not cover long-term care (like nursing home care), routine vision, dental, or hearing care, hearing aids, eye glasses, or private-duty nursing.

If you're enrolled in Medicare Part A and Part B, you're probably eligible to buy a Medicare Supplement policy. During your Medigap Open Enrollment Period - for people 65 or older, that's six months after you sign up for Medicare Part B - a company must allow you to buy any Medicare Supplement plan offered.

Medicare Supplement plans are purchased in addition to your Original Medicare benefits.

There are no specific enrollment dates for a Medicare Supplement (Medigap) plan. The best time to buy a plan is during your Medigap Open Enrollment Period which lasts 6 months. It starts on the first day of the month in which you are BOTH age 65 or older AND enrolled in Medicare Part B. If you are under age 65 and enrolled in Medicare by reason of disability or ESRD, there is a similar Open Enrollment Period for 6 months after the later of your enrollment in Part B or January 1, 2012. Once your Medigap Open Enrollment Period starts it cannot be changed. During this period you cannot be denied coverage, nor made to wait before coverage begins

You can still apply for a Medicare Supplement plan after your Medigap Open Enrollment Period has expired. However, your application may be subject to medical underwriting (i.e. a review of your medical history and current health) unless you qualify under guaranteed issue rights.

You also may have the right to buy a Medicare Supplement policy outside of your Medigap Open Enrollment Period if you lose certain types of health coverage. In general, this right is for 63 days from the date coverage ends or from the date you receive notice that your coverage will end. You must provide proof of the loss of your previous coverage. Otherwise, applying after your guaranteed acceptance period has expired may subject your application to medical underwriting which will help determine if your application will be accepted.

In general, your coverage begins on the first day of the month after BlueCross BlueShield of Tennessee receives your completed application - unless you request a later effective date, or you enrolled prior to your Medicare Part A or B effective date.

Medicare Supplement coverage is guaranteed renewable, which means BlueCross BlueShield of Tennessee cannot cancel your policy because of your age or health. You may be involuntarily disenrolled from the plan only under the following circumstances:

• Your Medicare Part A or Medicare Part B coverage ceases.
• You fail to pay any monthly plan premium.

No, but you may need to answer health questions during enrollment. Responses to medical questions are not required if you are enrolling during open enrollment or qualify for guaranteed issue.

In addition to the monthly Medicare Part B premium to Medicare, you pay a premium to the insurance company that provides your coverage. BlueCross BlueShield of Tennessee offers several ways to pay, including automatic bank account withdrawal or credit card.

Your monthly premiums are based on your age as of the June 1 prior to the effective date of your policy. Your monthly premiums will increase each year based on your age, in addition to any other increases in premiums required.

No. With a Medicare Supplement plan, you have the flexibility to choose any doctor or hospital who accepts Medicare.

Click here to learn more about the BlueElite benefits available to you.

No. If you’re buying a Medicare Supplement plan and want prescription drug coverage, you’ll need to enroll in a separate Medicare Part D plan. Some supplement plans sold before 2006 included drug coverage; people who had already purchased those plans were allowed to keep the same coverage.