PARTCRX

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
BlueCross BlueShield of Tennessee
CMS Rating
Plan Type
PPO
Annual Drug Deductible
$0.00

What To Know About This Plan

  • This plan has health and drug coverage

Plan Details

Costs and Other Important Information

Plan Year:
2014
Optional Supplemental Benefits?
No
Choice of Doctors?
Any Doctor
Prescription Drugs Covered?
Yes
Out-Of-Pocket Spending Limit
$4,400 In-Network$8,800 In and Out-of-Network
Other Deductibles?
In Network: No. Out of Network: No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00

Benefits

Service
In Network
Out of Network
Inpatient Hospital Care
Days 1-4: $300 copay per day. Days 5-90: $0 copay per day
40%
Inpatient Mental Health Care
Days 1-4: $300 copay per day. Days 5-90: $0 copay per day
40%
Skilled Nursing Facility (SNF)
Days 1-4: $0 copay per day. Days 5-20: $25 copay per day. Days 21-100: $125 copay per day
40%
Home Health Care
$0
40% maximum per visit
Doctor Office Visits
$10 maximum per visit
40% maximum per visit
Outpatient Services
$300 maximum per visit
40% maximum per visit
Ambulance Services
$225 maximum
$225 maximum
Emergency Care
$65 maximum per visit
Not Applicable
Durable Medical Equipment
20% maximum per item
40% maximum per item
Kidney Disease and Conditions
20% maximum per visit
20% maximum per visit
Specialist Office Visit
$40 maximum per visit
40% maximum per visit

Prescription Drug Coverage

Drugs Covered under Medicare Part B

General

20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.

40% of the cost for Medicare Part B drugs out-of-network.


Drugs Covered under Medicare Part D

General

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://bcbst-medicare.com on the web.

Different out-of-pocket costs may apply for people who
  • have limited incomes,
  • live in long term care facilities, or
  • have access to Indian/Tribal/Urban (Indian Health Service) providers.


The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).

Total yearly drug costs are the total drug costs paid by both you and a Part D plan.

The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.

Some drugs have quantity limits.

Your provider must get prior authorization from BlueAdvantage Garnet (PPO) for certain drugs.

You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.

If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount.

If you request a formulary exception for a drug and BlueAdvantage Garnet (PPO) approves the exception, you will pay Tier 4: Non-Preferred Brand cost sharing for that drug.

In-Network

$0 deductible.

Initial Coverage

You pay the following until total yearly drug costs reach $2,850:

Retail Pharmacy

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

Tier 1: Preferred Generic

  • $3 copay for a one-month (30-day) supply of drugs in this tier


  • $9 copay for a three-month (90-day) supply of drugs in this tier


  • Tier 2: Non-Preferred Generic

  • $12 copay for a one-month (30-day) supply of drugs in this tier


  • $36 copay for a three-month (90-day) supply of drugs in this tier


  • Tier 3: Preferred Brand

  • $45 copay for a one-month (30-day) supply of drugs in this tier


  • $135 copay for a three-month (90-day) supply of drugs in this tier


  • Tier 4: Non-Preferred Brand

  • $80 copay for a one-month (30-day) supply of drugs in this tier


  • $240 copay for a three-month (90-day) supply of drugs in this tier


  • Tier 5: Specialty Tier

  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier


  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier


Long Term Care Pharmacy

Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

Tier 1: Preferred Generic

  • $3 copay for a one-month (31-day) supply of drugs in this tier


  • Tier 2: Non-Preferred Generic

  • $12 copay for a one-month (31-day) supply of drugs in this tier


  • Tier 3: Preferred Brand

  • $45 copay for a one-month (31-day) supply of drugs in this tier


  • Tier 4: Non-Preferred Brand

  • $80 copay for a one-month (31-day) supply of drugs in this tier


  • Tier 5: Specialty Tier

  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier



Mail Order


Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

Tier 1: Preferred Generic

  • $3 copay for a one-month (30-day) supply of drugs in this tier


  • $7.50 copay for a three-month (90-day) supply of drugs in this tier


  • Tier 2: Non-Preferred Generic

  • $12 copay for a one-month (30-day) supply of drugs in this tier


  • $30 copay for a three-month (90-day) supply of drugs in this tier


  • Tier 3: Preferred Brand

  • $45 copay for a one-month (30-day) supply of drugs in this tier


  • $112.50 copay for a three-month (90-day) supply of drugs in this tier


  • Tier 4: Non-Preferred Brand

  • $80 copay for a one-month (30-day) supply of drugs in this tier


  • $200 copay for a three-month (90-day) supply of drugs in this tier


  • Tier 5: Specialty Tier

  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier


  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier


Coverage Gap

After your total yearly drug costs reach $2,850, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan's costs for brand drugs and 72% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,550.

Additional Coverage Gap

The plan covers few formulary generics (less than 10% of formulary generic drugs) through the coverage gap.

The plan offers additional coverage in the gap for the following tiers. You pay the following:

Retail Pharmacy

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

Tier 1: Preferred Generic

  • $3 copay for a one-month (30-day) supply of all drugs covered within this tier


  • $9 copay for a three-month (90-day) supply of all drugs covered within this tier


Long Term Care Pharmacy

Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

Tier 1: Preferred Generic

  • $3 copay for a one-month (31-day) supply of all drugs covered within this tier



Mail Order


Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

Tier 1: Preferred Generic

  • $3 copay for a one-month (30-day) supply of all drugs covered within this tier


  • $7.50 copay for a three-month (90-day) supply of all drugs covered within this tier


Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of:
  • 5% coinsurance, or
  • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.


Out-of-Network

Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from BlueAdvantage Garnet (PPO).

You can get out-of-network drugs the following way:

Out-of-Network Initial Coverage

You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,850:

Out-of-Network Initial Coverage

Tier 1: Preferred Generic

  • $3 copay for a one-month (30-day) supply of drugs in this tier


  • Tier 2: Non-Preferred Generic

  • $12 copay for a one-month (30-day) supply of drugs in this tier


  • Tier 3: Preferred Brand

  • $45 copay for a one-month (30-day) supply of drugs in this tier


  • Tier 4: Non-Preferred Brand

  • $80 copay for a one-month (30-day) supply of drugs in this tier


  • Tier 5: Specialty Tier

  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier


You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

Out-of-Network Coverage Gap

You will be reimbursed up to 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s).

Additional Out-of-Network Coverage Gap

You will be reimbursed for these drugs purchased out-of-network up to the plan's cost of the drug minus the following:

Tier 1: Preferred Generic

  • $3 copay for a one-month (30-day) supply of all drugs covered within this tier


Out-of-Network Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share, which is the greater of:
  • 5% coinsurance, or
  • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.


You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.


Other Services

Inpatient Care

Doctor and Hospital Choice



In-Network

No referral required for network doctors, specialists, and hospitals.

In and Out-of-Network

You can go to doctors, specialists, and hospitals in or out of the network. It will cost more to get out of network benefits.

Out of Service Area

Plan covers you when you travel in the U.S. or its territories.


Inpatient Hospital Care



In-Network

No limit to the number of days covered by the plan each hospital stay.

For Medicare-covered hospital stays:

  • Days 1 - 4: $300 copay per day


  • Days 5 - 90: $0 copay per day


$0 copay for additional non-Medicare-covered hospital days

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.

Out-of-Network

40% of the cost for each Medicare-covered hospital stay.


Outpatient Care

Inpatient Mental Health Care



In-Network

You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

For Medicare-covered hospital stays:

  • Days 1 - 4: $300 copay per day


  • Days 5 - 90: $0 copay per day


Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.

Out-of-Network

40% of the cost for each Medicare-covered hospital stay.


Skilled Nursing Facility (SNF)



General

Authorization rules may apply.

In-Network

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

For SNF stays:

  • Days 1 - 4: $0 copay per day


  • Days 5 - 20: $25 copay per day


  • Days 21 - 100: $125 copay per day


Out-of-Network

40% of the cost for each Medicare-covered SNF stay.


Home Health Care



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered home health visits

Out-of-Network

40% of the cost for Medicare-covered home health visits


Hospice



General

You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.


Doctor Office Visits



In-Network

$10 copay for each Medicare-covered primary care doctor visit.

$40 copay for each Medicare-covered specialist visit.

Out-of-Network

40% of the cost for each Medicare-covered primary care doctor visit

40% of the cost for each Medicare-covered specialist visit


Outpatient Medical Services and Supplies

Chiropractic Services



General

Authorization rules may apply.

In-Network

$20 copay for each Medicare-covered chiropractic visit

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).

Out-of-Network

40% of the cost for Medicare-covered chiropractic visits.


Podiatry Services



In-Network

$30 copay for each Medicare-covered podiatry visit

Medicare-covered podiatry visits are for medically necessary foot care.

Out-of-Network

40% of the cost for Medicare-covered podiatry visits


Outpatient Mental Health Care



General

Authorization rules may apply.

In-Network

$40 copay for each Medicare-covered individual therapy visit

$40 copay for each Medicare-covered group therapy visit

$40 copay for each Medicare-covered individual therapy visit with a psychiatrist

$40 copay for each Medicare-covered group therapy visit with a psychiatrist

$45 copay for Medicare-covered partial hospitalization program services

Out-of-Network

40% of the cost for Medicare-covered Mental Health visits with a psychiatrist

40% of the cost for Medicare-covered Mental Health visits

40% of the cost for Medicare-covered partial hospitalization program services


Outpatient Substance Abuse Care



General

Authorization rules may apply.

In-Network

$45 copay for Medicare-covered individual substance abuse outpatient treatment visits

$45 copay for Medicare-covered group substance abuse outpatient treatment visits

Out-of-Network

40% of the cost for Medicare-covered substance abuse outpatient treatment visits


Outpatient Services



General

Authorization rules may apply.

In-Network

$300 copay for each Medicare-covered ambulatory surgical center visit

$300 copay for each Medicare-covered outpatient hospital facility visit

Out-of-Network

40% of the cost for Medicare-covered outpatient hospital facility visits

40% of the cost for Medicare-covered ambulatory surgical center visits


Ambulance Services



In-Network

$225 copay for Medicare-covered ambulance benefits.

Out-of-Network

$225 copay for Medicare-covered ambulance benefits.


Emergency Care



General

$65 copay for Medicare-covered emergency room visits

Worldwide coverage.

If you are admitted to the hospital within 3-day(s) for the same condition, you pay $0 for the emergency room visit.


Urgently Needed Care



General

$45 copay for Medicare-covered urgently-needed-care visits

If you are admitted to the hospital within 3-day(s) for the same condition, you pay $0 for the urgently-needed-care visit.


Outpatient Rehabilitation Services



General

Authorization rules may apply.

Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered.

In-Network

$40 copay for Medicare-covered Occupational Therapy visits

$40 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits

Out-of-Network

40% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits

40% of the cost for Medicare-covered Occupational Therapy visits.


Durable Medical Equipment



General

Authorization rules may apply.

In-Network

20% of the cost for Medicare-covered durable medical equipment

Out-of-Network

40% of the cost for Medicare-covered durable medical equipment


Preventive Services

Prosthetic Devices



General

Authorization rules may apply.

In-Network

20% of the cost for Medicare-covered prosthetic devices

20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices

Out-of-Network

40% of the cost for Medicare-covered prosthetic devices.


Diabetes Programs and Supplies



In-Network

$0 copay for Medicare-covered Diabetes self-management training

$0 copay for Medicare-covered:

  • Diabetes monitoring supplies


  • Therapeutic shoes or inserts


If the doctor provides you services in addition to Diabetes self-management training, separate cost sharing of $10 to $40 may apply

Out-of-Network

20% of the cost for Medicare-covered Diabetes monitoring supplies

20% of the cost for Medicare-covered Therapeutic shoes or inserts

20% of the cost for Medicare-covered Diabetes self-management training

If the doctor provides you services in addition to (Diabetes Self-Management Training ), separate cost sharing of 40% of the cost may apply


Diagnostic Tests, X-Rays, Lab Services, and Radiology Services



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered lab services

$0 copay for Medicare-covered diagnostic procedures and tests

$0 copay for Medicare-covered X-rays

$200 copay for Medicare-covered diagnostic radiology services (not including X-rays)

$60 copay for Medicare-covered therapeutic radiology services

Out-of-Network

40% of the cost for Medicare-covered therapeutic radiology services

40% of the cost for Medicare-covered outpatient X-rays

40% of the cost for Medicare-covered diagnostic radiology services

40% of the cost for Medicare-covered diagnostic procedures and tests

40% of the cost for Medicare-covered lab services


Cardiac and Pulmonary Rehabilitation Services



In-Network

$40 copay for Medicare-covered Cardiac Rehabilitation Services

$40 copay for Medicare-covered Intensive Cardiac Rehabilitation Services

$40 copay for Medicare-covered Pulmonary Rehabilitation Services

Out-of-Network

40% of the cost for Medicare-covered Cardiac Rehabilitation Services

40% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services

40% of the cost for Medicare-covered Pulmonary Rehabilitation Services


Additional Benefits

Preventive Services



General

$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.

Out-of-Network

40% of the cost for Medicare-covered preventive services


Kidney Disease and Conditions



In-Network

20% of the cost for Medicare-covered renal dialysis

$0 copay for Medicare-covered kidney disease education services

Out-of-Network

20% of the cost for Medicare-covered kidney disease education services

20% of the cost for Medicare-covered renal dialysis


Dental Services



In-Network

In general, preventive dental benefits (such as cleaning) not covered.

$40 copay for Medicare-covered dental benefits

Out-of-Network

40% of the cost for Medicare-covered comprehensive dental benefits


Hearing Services



In-Network

Hearing aids not covered.

$15 copay for Medicare-covered diagnostic hearing exams

$15 copay for up to 1 supplemental routine hearing exam(s) every year

Out-of-Network

$15 copay for Medicare-covered diagnostic hearing exams.

$15 copay for supplemental hearing exams.


Vision Services



In-Network

$40 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk

$40 copay for up to 1 supplemental routine eye exam(s) every year

$0 copay for
  • one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery


  • eyeglasses (lenses and frames)


  • contact lenses


  • eyeglass lenses


  • eyeglass frames


Out-of-Network

$0 copay for Medicare-covered eyewear

$0 copay for supplemental eyewear

$40 copay for Medicare-covered eye exams

$40 copay for supplemental routine eye exams

In and Out-of-Network

$100 plan coverage limit for supplemental eyewear every year. This limit applies to both in-network and out-of-network benefits.


Cost Sharing Information

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$4 copay$4 copay$4 copay
Tier 2: Non-Preferred Generic$12 copay$12 copay$12 copay
Tier 3: Preferred Brand Name$45 copay$45 copay$45 copay
Tier 4: Non-Preferred Brand Name$80 copay$80 copay$80 copay
Tier 5: Specialty Tier33% coinsurance33% coinsurance33% coinsurance
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$12 copay$12 copay$10 copay
Tier 2: Non-Preferred Generic$36 copay$36 copay$30 copay
Tier 3: Preferred Brand Name$135 copay$135 copay$112.5 copay
Tier 4: Non-Preferred Brand Name$240 copay$240 copay$200 copay
Tier 5: Specialty Tier33% coinsurance33% coinsurance33% coinsurance

CMS Ratings

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Not Rated
Colorectal cancer screening
Cholesterol screening for patients with heart disease
Glaucoma testing
Annual flu vaccine
Pneumonia vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Access to primary care doctor visits
Adult BMI assessment

Managing Chronic Conditions

Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not Rated
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Diabetes care – cholesterol controlled
Controlling blood pressure
Rheumatoid arthritis management
Improving bladder control
Reducing the risk of falling
Plan all-cause readmissions

Ratings of Plan Responsiveness and Care

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan

Member Complaints, Problems Getting Services, and Choosing to Leave the Plan

Complaints about the health plan
Beneficiary access and performance problems
Members choosing to leave the plan
Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability

Physician Finder

Physicians that accept BlueAdvantage Garnet (PPO) for Tennessee

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