Notices and Disclaimers

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, formulary, pharmacy network, premium, co-payments and coinsurance amounts may change on January 1, 2013.

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

You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. If you request premiums withheld, elect to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months for the change to take effect and you will be held responsible for those premiums.

Limitations, copayments and restrictions may apply.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week;
  
• The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
  
• Your State Medicaid Office.

Members may enroll in the plan only during specific times of the year. Contact BlueAdvantage for more information.

Individuals must have both Part A and Part B to enroll.

All services must be covered by Medicare or the BlueAdvantage PPO plan and received from network providers for these cost sharing amounts to apply. With the exception of emergencies or urgent care, it may cost more to get care from out-of-network providers. For a complete list of benefits as compared to Original Medicare, please see the Summary of Benefits. For detailed information on a BlueAdvantage PPO plan and its limitations, copayments and restrictions, please review the Evidence of Coverage. For full information on BlueAdvantage PPO please contact us.

A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your provider is not required to agree to accept the plan’s terms and conditions, and thus may choose not to treat you, with the exception of emergencies. If your provider does not agree to accept our payment terms and conditions of payment, they may choose not to provide health care services to you, except in emergencies. If this happens, you will need to find another provider that will accept our payment terms and conditions. Providers can find the plan’s terms and conditions on our website at: www.bcbst.com/providers/BenefitHighlights.shtml.

For more information, please read:
What People on Medicare Need to Know about Private Fee-For-Service Plans 

BlueAdvantage and BlueRx cover both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a 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 effective as brand name drugs.

The formulary may change during the year.

You must use network pharmacies to access your prescription drug benefits, except under non-routine circumstances; quantity limitations and restrictions may apply.

BlueAdvantage and BlueRx has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area