BlueAdvantage Ruby (PPO)

  In-Network Benefits
Plan Name  BlueAdvantage Ruby (PPO)
Plan Type Preferred Provider Organization
Monthly Premium You pay:
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Low Income Subsidy View Plan Premiums for People Who Receive Extra Help
Out-of-Pocket Maximum $4,800
Doctor Office Visits2 $20 copay
Specialist Visit2 $40 copay
Inpatient Hospital Care1 You pay $275 per day for days 1-4. You pay $0 for additional days received at a hospital. Unlimited Days
Outpatient Surgical Services1,2 You pay $250 per visit. 
Inpatient Mental Health Care1 You pay $275 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 $20-$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 Services2 $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 Care1,2 $40 copay
Outpatient Substance Abuse Care2 $40 copay
Ambulance Services2 $175 copay
Emergency Care2 $65 copay
Urgently Needed Care2 $40 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 $20-$50 copay
Advanced Imaging1 20% of the cost
Therapeutic Radiology2 20% of the cost
Cardiac/Pulmonary Rehab2 $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: $7 copay
Tier 2 - Preferred Brand Drugs: $30 copay
Tier 3 - Non-Preferred Brand Drugs: $75 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: $17.50 copay
Tier 2 - Preferred Brand Drugs: $75 copay
Tier 3 - Non-Preferred Brand Drugs: $187.50 copay
Tier 4 - Specialty Drugs: 33% coinsurance
Additional Resources  
Health Education and Wellness BluePerks offsite link
Health Management
Formulary (Drug Search) Click here to see if your drugs are covered on the BlueAdvantage Ruby (PPO) Formularyoffsite link
Pharmacy Find a Network Pharmacy offsite link
Save money through the mail-order pharmacy program
Provider Directory Is your doctor covered in our network? offsite link
Member Rights Coverage Decisions, Appeals & Complaints
Downloads Summary of Benefits
Formulary
Notice of Formulary Change
Health Plan Rating Information
Transition Policy
  Notices and Disclaimers
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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.


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A health plan with a Medicare contract
Y0013_W12_R2 CMS Approved 01052012
A Medicare approved Part D sponsor
S1030_W12_R2 CMS Approved 01052012