BlueAdvantage Gold Benefit Highlights 2007

BlueAdvantage Gold Benefit Highlights 2007

Service

Member Cost-Share Amount

Ambulance services

$100 co-payment per date of service

Chiropractic services (covered by Medicare)

$20 co-payment

Dental services

Dental preventive services covered up to a maximum of $100 per calendar year. No co-payment.

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)

$20 co-payment for exam ($25 co-payment for eyewear following cataract surgery)

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

$20 co-payment for each routine eye exam.

Hearing Exams (covered by Medicare)

$20 co-payment

Hearing Exams (routine) One exam every 2 years

$20 co-payment

Home health services

No co-payment

Immediate Care Facility

$20 co-payment

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)

$250 co-payment per admit (unlimited days)

Inpatient hospital (psych)  – 190 day lifetime limit

$250 co-payment per admit (unlimited days)

Office Visit

$20 co-payment covered service

Outpatient Lab Services

No co-payment

Outpatient Mental Heath (Medicare covered)

$20 co-payment

Outpatient Substance Abuse (Medicare covered)

$20 co-payment

Outpatient radiation therapy, X-rays and radiology

No co-payment

Outpatient services (other than surgical)

$20 co-payment

Outpatient Surgical Service

$100 co-payment

Outpatient therapy—physical, speech, occupational and cardiac therapies

$20 co-payment

Partial hospitalization for mental health

$20 co-payment per date of service

Podiatry services (covered by Medicare)

$20 co-payment

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-payment

Renal dialysis

$20 co-payment per date of service – all settings

Routine Physical (1 per year)

No co-payment

Skilled Nursing Facility

$75 co-payment per day (days 21-100); no 3 day hospital stay; 100 days per benefit period

Specialty Care Physician
(including mental health providers)

$20 co-payment

Urgent Care

$20 co-payment at primary care physician or specialist’s office

$20 co-payment at immediate care facility

$50 co-payment at a hospital emergency room

Page Modified:May 21, 2012