BlueAdvantage Complete Benefit Highlights

BlueAdvantage Complete Benefit Highlights 2007

Service

Member Cost-Share Amount

Ambulance services

20% co-payment per date of service

Chiropractic services (covered by Medicare)

20% co-payment

Dental services

No co-payment for 2 preventive visits per year

Diabetic monitoring supplies

20% co-insurance

Durable medical equipment

20% co-insurance

Emergency room

$50 co-payment (waived if admitted)

Eye Exams/Wear (covered by Medicare)

No co-payment for exam ($100 allowance per year for eyewear)

Eye Exams (routine). One exam every calendar year.

No co-payment for exam ($100 allowance per year for eyewear)

Hearing Exams (covered by Medicare)

No co-payment

Hearing Exams (routine) One exam every 2 years

No co-payment

Home health services

No co-payment

Immediate Care Facility

20% co-insurance

Immunizations (flu vaccine, Hepatitis B – for at risk, Pneumonia vaccine)

No co-payment pneumonia  flu vaccine

No co-payment hepatitis B vaccine

Inpatient hospital (med/surg)

$1000 co-payment per admit (per benefit period) + $250 per day for days 61-90 + $500 per day for days 91-150

Inpatient hospital (psych)

$1000 co-payment per admit (per benefit period) + $250 per day for days 61-90 + $500 per day for days 91-150

Office Visit

20% co-insurance covered service

Outpatient Lab Services

20% co-insurance

Outpatient Mental Heath (Medicare covered)

20% co-insurance

Outpatient Substance Abuse (Medicare covered)

20% co-insurance

Outpatient radiation therapy, X-rays and radiology

20% co-insurance

Outpatient services (other than surgical)

20% co-insurance

Outpatient Surgical Service

20% co-insurance

Outpatient therapy—physical, speech, occupational and cardiac therapies

20% co-insurance

Partial hospitalization for mental health

20% co-insurance

Podiatry services (covered by Medicare)

20% co-insurance

Preventive Services—immunizations, bone mass measurement, diabetes self-management, colorectal screening, nutritional therapy (diabetic or ESRD patients), pap smears and pelvic exam screenings, prostate cancer screening and mammography

No co-payment.

Primary Care Office

20% co-insurance

Renal dialysis

20% co-insurance

Routine Physical (1 per year)

No co-payment

Skilled Nursing Facility

$125 co-payment per day (days 21-100); requires 3 day hospital stay; 100 days per benefit period

Specialty Care Physician
(including mental health providers)

20% co-insurance

Urgent Care

20% co-insurance at primary care physician or specialist’s office

20% co-insurance at immediate care facility

$50 co-payment at a hospital emergency room

Page Modified:May 21, 2012