Blueadvantage (PPO) Summary Of Benefits 2018

1 Blueadvantage (PPO) SM. Summary of Benefits 2018 . Blueadvantage Diamond (PPO)SM. Blueadvantage Ruby (PPO)SM. Blueadvantage Sapphire (PPO)SM Blueadvantage Garnet (PPO)SM. H7917_18_SB Accepted 09012017. This is a Summary of drug and health services covered by Blueadvantage (PPO) health plans There is more than January 1, 2018 - December 31, 2018 . one plan listed in this Summary of Benefits . BlueCross BlueShield of Tennessee, Inc., Blueadvantage Preferred provider is a PPO plan with a Medicare contract. Organization (PPO) plans have a network of Enrollment in BlueCross BlueShield of doctors, hospitals, pharmacies, and other Tennessee, Inc. depends on contract providers. If you use the providers in our renewal. These plans do not require referrals network, you may pay less for your covered to see specialists.

2 Services. But if you want to, you can use providers that are not in our network as long The benefit information provided is a as they participate in Medicare. Summary of what we cover and what you pay. It does not list every service that we Out-of-network/non-contracted providers are cover or list every limitation or exclusion. under no obligation to treat BlueAdvantageSM. To get a complete list of services we cover, members, except in emergency situations. please request the "Evidence of Coverage" For a decision about whether we will cover by contacting member service or access it an out-of-network service, we encourage online by visiting you or your provider to ask us for a pre . service organization determination before To join Blueadvantage (PPO), you must be you receive the service.

3 Please call our entitled to Medicare Part A, be enrolled customer service number or see your in Medicare Part B, and live in our service Evidence of Coverage for more information, area. Our service area includes the including the cost-sharing that applies to out . Tennessee counties listed on the next two of-network services. pages organized by region. ii Blueadvantage Blueadvantage Blueadvantage Premiums Sapphire &. Ruby (PPO) Diamond (PPO). Garnet (PPO). Monthly Plan You must continue to pay your Medicare Part B premium. Medicare Part B. Premium by premiums and plan premiums do not apply to your maximum out-of-pocket limit. Region Northeast - Counties $0 per month for $72 per month $111 per month include: Sapphire Carter, Greene, Hancock, Hawkins, Johnson, Sullivan, Unicoi, Washington Garnet is not available in this area Southeast - Counties $0 per month for $87 per month $213 per month include: Sapphire Anderson, Bledsoe, Blount, Bradley, Campbell, Cannon, Claiborne, Clay, Cocke, Garnet is not available in Cumberland, Dekalb, this area Fentress, Franklin, Grainger, Grundy, Hamblen, Hamilton, Jackson, Jefferson, Knox, Loudon, Macon, Marion, McMinn, Meigs, Monroe, Morgan, Overton, Pickett, Polk, Putnam, Rhea, Roane, Scott, Sequatchie, Sevier, Smith, Union, Van Buren, Warren, White iii Blueadvantage Premiums & Blueadvantage Blueadvantage Sapphire &.

4 Health Benefits Ruby (PPO) Diamond (PPO). Garnet (PPO). Middle - Counties $0 per month for Garnet $102 per month $217 per month include: Bedford, Cheatham, Coffee, Davidson, Dickson, Giles, Hickman, Houston, Humphreys, Lawrence, Sapphire is not available in this area Lewis, Lincoln, Marshall, Maury, Montgomery, Moore, Perry, Robertson, Rutherford, Stewart, Sumner, Trousdale, Wayne, Williamson, Wilson West - Counties $0 per month for Garnet $92 per month $188 per month include: Benton, Carroll, Chester, Crockett, Decatur, Dyer, Fayette, Gibson, Hardeman, Hardin, Haywood, Henderson, Sapphire is not available Henry, Lake, Lauderdale, in this area Madison, McNairy, Obion, Shelby, Tipton, Weakley Deductible No Deductible No Deductible No Deductible The most you pay for copays, coinsurance and other costs for medical services for the year.

5 Expenses that do not apply include: Plan premiums Maximum Copays or coinsurance for preventive or comprehensive dental services Out-of-Pocket Copays or coinsurance for routine eye exam or eyewear Responsibility Copays or coinsurance for routine hearing exam or hearing aid(s). Copays or coinsurance for Part D covered diabetic supplies Copays or coinsurance for Part D prescription drug expenses In-network: In-network: In-network: $6,700 annually $4,800 annually $3,700 annually Combined In and Combined In and Combined In and Out-of-network: Out-of-network: Out-of-network: $10,000 annually $10,000 annually $10,000 annually iv Health Benefits Blueadvantage Blueadvantage Blueadvantage Health Benefits Sapphire &. Ruby (PPO) Diamond (PPO). Garnet (PPO). Inpatient Hospital Prior authorization required.

6 Coverage In-network: In-network: In-network: $300 copay per day for $260 copay per day for $175 copay per day for days 1 through 5 days 1 through 4 days 1 through 4. $0 copay per day for $0 copay per day for $0 copay per day for days 6 and beyond days 5 and beyond days 5 and beyond Out-of-network: 50% Out-of-network: 50% Out-of-network: 50%. of the Medicare allowed of the Medicare allowed of the Medicare allowed amount per stay amount per stay amount per stay The amounts above apply The amounts above apply The amounts above apply per benefit period. per benefit period. per benefit period. A benefit period begins A benefit period begins A benefit period begins the day you are admitted the day you are admitted the day you are admitted or transferred to a or transferred to a or transferred to a hospital and ends when hospital and ends when hospital and ends when you are discharged.

7 If you you are discharged. If you you are discharged. If you are readmitted, a new are readmitted, a new are readmitted, a new benefit period begins. benefit period begins. benefit period begins. Our plan covers an Our plan covers an Our plan covers an unlimited number of unlimited number of unlimited number of days for an inpatient days for an inpatient days for an inpatient hospital stay. hospital stay. hospital stay. Outpatient May require prior authorization. Hospital Coverage + Ambulatory In-network: In-network: In-network: Surgical Center $275 copay $210 copay $125 copay Out-of-network: Out-of-network: Out-of-network: 50% of the Medicare 50% of the Medicare 50% of the Medicare allowed amount allowed amount allowed amount + Outpatient Hospital In-network: In-network: In-network: $325 copay $260 copay $175 copay Out-of-network: Out-of-network: Out-of-network: 50% of the Medicare 50% of the Medicare 50% of the Medicare allowed amount allowed amount allowed amount v Blueadvantage Blueadvantage Blueadvantage Health Benefits Sapphire &.

8 Ruby (PPO) Diamond (PPO). Garnet (PPO). Doctor Visits + Primary Care In-network: In-network: In-network: Providers $10 copay per visit $15 copay per visit $15 copay per visit Out-of-network: Out-of-network: Out-of-network: 50% of the Medicare 50% of the Medicare 50% of the Medicare allowed amount allowed amount allowed amount + Specialists In-network: In-network: In-network: $35 copay per visit $35 copay per visit $30 copay per visit Out-of-network: Out-of-network: Out-of-network: 50% of the Medicare 50% of the Medicare 50% of the Medicare allowed amount allowed amount allowed amount Preventive Care Any additional preventive services approved by Medicare during the contract year will be covered. Our plan covers many preventive services, including: + Abdominal In-network: $0 copay In-network: $0 copay In-network: $0 copay aortic aneurysm Out-of-network: Out-of-network: Out-of-network: screening 50% of the Medicare 50% of the Medicare 50% of the Medicare allowed amount allowed amount allowed amount + Alcohol misuse In-network: $0 copay In-network: $0 copay In-network: $0 copay counseling Out-of-network: Out-of-network: Out-of-network: 50% of the Medicare 50% of the Medicare 50% of the Medicare allowed amount allowed amount allowed amount + Bone mass In-network: $0 copay In-network: $0 copay In-network: $0 copay measurement Out-of-network: Out-of-network: Out-of-network.

9 50% of the Medicare 50% of the Medicare 50% of the Medicare allowed amount allowed amount allowed amount + Breast cancer In-network: $0 copay In-network: $0 copay In-network: $0 copay screening Out-of-network: Out-of-network: Out-of-network: (mammogram) 50% of the Medicare 50% of the Medicare 50% of the Medicare allowed amount allowed amount allowed amount vi Blueadvantage Blueadvantage Blueadvantage Health Benefits Sapphire &. Ruby (PPO) Diamond (PPO). Garnet (PPO). + Cardiovascular In-network: $0 copay In-network: $0 copay In-network: $0 copay disease Out-of-network: Out-of-network: Out-of-network: (behavioral 50% of the Medicare 50% of the Medicare 50% of the Medicare therapy) allowed amount allowed amount allowed amount + Cardiovascular In-network: $0 copay In-network: $0 copay In-network: $0 copay screenings Out-of-network: Out-of-network: Out-of-network: 50% of the Medicare 50% of the Medicare 50% of the Medicare allowed amount allowed amount allowed amount + Cervical and In-network: $0 copay In-network: $0 copay In-network: $0 copay vaginal cancer Out-of-network: Out-of-network: Out-of-network.

10 Screening 50% of the Medicare 50% of the Medicare 50% of the Medicare allowed amount allowed amount allowed amount + Colorectal cancer In-network: $0 copay In-network: $0 copay In-network: $0 copay screenings Out-of-network: Out-of-network: Out-of-network: (Colonoscopy, 50% of the Medicare 50% of the Medicare 50% of the Medicare Fecal occult blood allowed amount allowed amount allowed amount test, Flexible sigmoidoscopy). + Depression In-network: $0 copay In-network: $0 copay In-network: $0 copay screening Out-of-network: Out-of-network: Out-of-network: 50% of the Medicare 50% of the Medicare 50% of the Medicare allowed amount allowed amount allowed amount + Diabetes In-network: $0 copay In-network: $0 copay In-network: $0 copay screenings Out-of-network: Out-of-network: Out-of-network: 50% of the Medicare 50% of the Medicare 50% of the Medicare allowed amount allowed amount allowed amount + HIV screening In-network: $0 copay In-network: $0 copay In-network: $0 copay Out-of-network: Out-of-network: Out-of-network: 50% of the Medicare 50% of the Medicare 50% of the Medicare allowed amount allowed amount allowed amount + Medical nutrition In-network: $0 copay In-network.