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