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 |
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 |
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