BlueAdvantage Garnet (PPO)

	In-Network Benefits
Plan Name	BlueAdvantage Garnet (PPO)
Plan Type	Preferred Provider Organization
Monthly Premium	You pay: $0 Enroll Now
Low Income Subsidy	View Plan Premiums for People Who Receive Extra Help
Out-of-Pocket Maximum	$4,950
Doctor Office Visits2	$30 copay
Specialist Visit2	$45 copay
Inpatient Hospital Care1	You pay $300 per day for days 1-4. You pay $0 for additional days received at a hospital. Unlimited Days
Outpatient Surgical Services1,2	You pay $400 per visit.
Inpatient Mental Health Care1	You pay $300 per day for days 1-4. You pay $0 for days 5-190 in same admission. There is a 190-day lifetime limit.
SilverSneakers Fitness Center Membership	$0 copay
X-Rays2	$30-$50 copay
Lab Services2	$0-$50 copay
Preventive Services	$0 copay
Part B - Covered Drugs1	20% coinsurance
Skilled Nursing Facility1	You pay $0 for days 1-4. You pay $50 per day for days 5-20. You pay $125 per day for days 21-100.
Home Health Care1,2	$0 copay
Hospice	You must get care from a Medicare-certified Hospice.
Chiropractic Services2	$15 copay
Podiatry Services 2	$30 copay
Durable Medical Equipment1,2	20% of the allowed amount for Medicare-covered items.
Prosthetic Devices1,2	20% of the cost for each item
Outpatient Mental Health Care 1,2	$40 copay
Outpatient Substance Abuse Care2	$45 copay
Ambulance Services2	$175 copay
Emergency Care2	$65 copay
Urgently Needed Care2	$45 copay
Outpatient Rehabilitation Services1,2	$40 copay
Diabetes Self-Monitoring Training, Nutrition Therapy and Supplies	0% for Diabetes Self-Monitoring Training. 0% for Nutrition Therapy for Diabetes. 20% of the cost for Diabetes Supplies.
Diagnostic Tests2	$30-$50 copay
Advanced Imaging1	20% of the cost
Therapeutic Radiology2	20% of the cost
Cardiac/Pulmonary Rehab 2	$40 copay
Abdominal Aortic Aneurysm Screening	$0 copay
Bone Mass Measurement	$0 copay
Colorectal Screening Exams	$0 copay
Immunizations/vaccines	$0 copay
Mammograms (Annual Screenings)	$0 copay
Pap Smears and Pelvic Exams	$0 copay
Prostate Cancer Screening Exams	$0 copay
Dialysis (kidney)	20% of the cost
Annual Physical Exam	$0 copay
Hearing Services	$15 copay for each diagnostic hearing exam. $15 copay for each routine hearing test
Vision Care	$35 copay for each diagnostic vision exam. $35 copay for each routine exam every year. Plan pays $175 towards glasses or contacts
Prescription Drug Benefits
Retail Pharmacy To the right are the prices for a 30-day supply of a drug in the tiers listed.	Tier 1 - Generic Drugs: $8 copay Tier 2 - Preferred Brand Drugs: $45 copay Tier 3 - Non-Preferred Brand Drugs: $80 copay Tier 4 - Specialty Drugs: 33% coinsurance
Mail Pharmacy To the right are the prices for a 90-day supply of a drug in the tiers listed.	Tier 1 - Generic Drugs: $20 copay Tier 2 - Preferred Brand Drugs: $112.50 copay Tier 3 - Non-Preferred Brand Drugs: $200 copay Tier 4 - Specialty Drugs: 33% coinsurance
Additional Resources
Health Education and Wellness	BluePerks Health Management
Formulary (Drug Search)	Click here to see if your drugs are covered on the BlueAdvantage Garnet (PPO) Formulary
Pharmacy	Find a Network Pharmacy Save money through the mail-order pharmacy program
Provider Directory	Is your doctor covered in our network?
Member Rights	Coverage Decisions, Appeals & Complaints
Downloads	Summary of Benefits Formulary Notice of Formulary Change Health Plan Rating Information Transition Policy
	Notices and Disclaimers
	Enroll Now

¹Authorization rules may apply. ²Medicare covered visits, benefits, services and/or items.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan.

In-Network benefit information is shown above. Except for emergencies or urgent care, it may cost more to get care from out-of-network providers.