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2011 Medicare Advantage Plan Benefit Details for the BlueAdvantage Emerald (PPO) - H7917-026-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2011 Medicare Advantage Plan Details
Medicare Plan Name:BlueAdvantage Emerald (PPO)
Location:Giles, Tennessee     Click to see other locations
Plan ID:H7917 - 026 - 0     Click to see other plans
Member Services:1-800-841-7434 TTY users 1-888-423-9490
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the BlueAdvantage Emerald (PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$99.00 (see Plan Premium Details below)
Annual Deductible:no drug coverage
Health Plan Type:Local PPO *
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$4,900
Number of Members enrolled in this plan in (H7917 - 026):46 members
— Plan Premium Details —
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Cost **
Premium and Other Important Information
$99.00 monthly plan premium in addition to your monthly Medicare Part B premium.
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
This plan covers all Medicare-covered preventive services with zero cost sharing.
$4 900 out-of-pocket limit.
This limit includes only Medicare-covered services.
$5 900 out-of-pocket limit.
In-Network: This limit includes only Medicare-covered services.
Out-Of-Network: This limit includes only Medicare-covered services.
** Doctor and Hospital Choice **
Doctor and Hospital Choice
No referral required for network doctors specialists and hospitals.
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits.
Plan covers you when you travel in the U.S.
** Extra Benefits **
Prescription Drugs
Most drugs not covered.
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.
25% of the cost for Part B drugs out-of-network.
This plan does not offer prescription drug coverage.
Physical Exams
$0 copay for routine exams.
Limited to 1 exam(s) every year.
$0 copay for routine exams.
Vision Services
$0 copay for
  • one pair of eyeglasses or contact lenses after cataract surgery
  • glasses
  • contacts
  • lenses
  • frames
  • $0 to $35 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $35 copay for up to 1 routine eye exam(s) every year
    • $100 plan coverage limit for eye wear every two years.
    $35 copay for eye exams.
    $0 copay for eye wear.
    Dental Services
    $0 copay for Medicare-covered dental benefits.
    $0 copay for the following preventive dental benefits:
  • oral exams
  • cleanings
  • fluoride treatments
  • dental x-rays
    • $0 copay for preventive dental benefits.
    $0 copay for comprehensive dental benefits.
    $100 plan coverage limit for dental benefits every year. This limit applies to both in-network and out-of-network benefits.
    Contact the plan for availability of additional in-network and out-of-network comprehensive dental benefits.
    ** Important Information **
    Premium and Other Important Information
    $99.00 monthly plan premium in addition to your monthly Medicare Part B premium.
    Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
    This plan covers all Medicare-covered preventive services with zero cost sharing.
    $4 900 out-of-pocket limit.
    This limit includes only Medicare-covered services.
    $5 900 out-of-pocket limit.
    In-Network: This limit includes only Medicare-covered services.
    Out-Of-Network: This limit includes only Medicare-covered services.
    Doctor and Hospital Choice
    No referral required for network doctors specialists and hospitals.
    You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits.
    Plan covers you when you travel in the U.S.
    ** Inpatient Care **
    Inpatient Hospital Care (Acute)
    No limit to the number of days covered by the plan each benefit period.
    For Medicare-covered hospital stays:
    Days 1 - 6: $175 copay per day
    Days 7 - 90: $0 copay per day
    $0 copay for additional hospital days
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    For hospital stays:
    Days 1 - 6: $275 copay per day
    Days 7 and beyond: $0 copay per day
    Inpatient Mental Health Care
    You get up to 190 days in a Psychiatric Hospital in a lifetime.
    For Medicare-covered hospital stays:
    Days 1 - 6: $175 copay per day
    Days 7 - 90: $0 copay per day
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    For hospital stays:
    Days 1 - 6: $275 copay per day
    Days 7 and beyond: $0 copay per day
    Skilled Nursing Facility (SNF)
    Authorization rules may apply.
    Plan covers up to 100 days each benefit period
    No prior hospital stay is required.
    For SNF stays:
    Days 1 - 7: $0 copay per day
    Days 8 - 20: $50 copay per day
    Days 21 - 100: $100 copay per day
    For each SNF stay:
    Days 1 - 7: $0 copay per SNF day
    Days 8 - 20: $100 copay per SNF day
    Days 21 - 100: $200 copay per SNF day
    Home Health Care
    Authorization rules may apply.
    $0 copay for Medicare-covered home health visits.
    $0 copay for home health visits.
    Hospice
    You must get care from a Medicare-certified hospice.
    ** Outpatient Care **
    Doctor Office Visits
    See 'Welcome to Medicare; and Annual Wellness Visit' for more information.
    $20 copay for each primary care doctor visit for Medicare-covered benefits.
    $35 copay for each in-area network urgent care Medicare-covered visit.
    $35 copay for each specialist visit for Medicare-covered benefits.
    $30 copay for each primary care doctor visit.
    $45 copay for each specialist visit.
    Chiropractic Services
    $20 copay for each Medicare-covered 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) if you get it from a chiropractor or other qualified providers.
    $45 copay for chiropractic benefits.
    Podiatry Services
    $35 copay for each Medicare-covered visit.
    Medicare-covered podiatry benefits are for medically-necessary foot care.
    $45 copay for podiatry benefits.
    Outpatient Mental Health Care
    $35 copay for each Medicare-covered individual or group therapy visit.
    $45 copay for Mental Health benefits.
    $45 copay for Mental Health benefits with a psychiatrist.
    Outpatient Substance Abuse Care
    $35 copay for Medicare-covered individual or group visits.
    $45 copay for outpatient substance abuse benefits.
    Outpatient Hospital Services
    Authorization rules may apply.
    $225 copay for each Medicare-covered ambulatory surgical center visit.
    $225 copay for each Medicare-covered outpatient hospital facility visit.
    $400 copay for ambulatory surgical center benefits.
    $400 copay for outpatient hospital facility benefits.
    Emergency Care
    $50 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
    Outpatient Rehabilitation Services
    Authorization rules may apply.
    $20 copay for Medicare-covered Occupational Therapy visits.
    $20 copay for Medicare-covered Physical and/or Speech and Language Therapy visits.
    $20 copay for Medicare-covered Cardiac Rehab services.
    $45 copay for Occupational Therapy benefits.
    $45 copay for Physical and/or Speech and Language Therapy visits.
    $45 copay for Cardiac Rehab services.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    20% of the cost for Medicare-covered items.
    30% of the cost for durable medical equipment.
    Prosthetic Devices
    20% of the cost for Medicare-covered items.
    30% of the cost for prosthetic devices.
    Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies
    $0 copay for Diabetes self-monitoring training.
    $0 copay for Nutrition Therapy for Diabetes.
    $0 copay for Diabetes supplies.
    $0 copay for Diabetes self-monitoring training.
    $0 copay for Nutrition Therapy for Diabetes.
    $0 copay for Diabetes supplies.
    ** Preventive Services **
    Bone Mass Measurement
    $0 copay for Medicare-covered bone mass measurement.
    Separate Office Visit cost sharing of $20 to $35 may apply.
    $0 copay for Medicare-covered bone mass measurement.
    Colorectal Screening Exams
    $0 copay for Medicare-covered colorectal screenings.
    Separate Office Visit cost sharing of $20 to $35 may apply.
    $0 copay for colorectal screenings.
    Immunizations
    $0 copay for Flu and Pneumonia vaccines.
    No referral needed for Flu and pneumonia vaccines.
    $0 copay for Hepatitis B vaccine.
    $0 copay for immunizations.
    Pap Smears and Pelvic Exams
    $0 copay for Medicare-covered pap smears and pelvic exams
    Separate Office Visit cost sharing of $20 to $35 may apply.
    $0 copay for pap smears and pelvic exams.
    Prostate Cancer Screening Exams
    $0 copay for Medicare-covered prostate cancer screening.
    Separate Office Visit cost sharing of $20 to $35 may apply.
    $0 copay for prostate cancer screening.
    ** Additional Benefits **
    Dialysis
    20% of the cost for renal dialysis
    $0 copay for Nutrition Therapy for End-Stage Renal Disease.
    20% of the cost for renal dialysis.
    $0 copay for Nutrition Therapy for End-Stage Renal Disease.
    Prescription Drugs
    Most drugs not covered.
    20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.
    25% of the cost for Part B drugs out-of-network.
    This plan does not offer prescription drug coverage.
    Dental Services
    $0 copay for Medicare-covered dental benefits.
    $0 copay for the following preventive dental benefits:
  • oral exams
  • cleanings
  • fluoride treatments
  • dental x-rays
    • $0 copay for preventive dental benefits.
    $0 copay for comprehensive dental benefits.
    $100 plan coverage limit for dental benefits every year. This limit applies to both in-network and out-of-network benefits.
    Contact the plan for availability of additional in-network and out-of-network comprehensive dental benefits.
    Hearing Services
    Hearing aids not covered.
  • $35 copay for Medicare-covered diagnostic hearing exams
  • $35 copay for up to 1 routine hearing test(s) every two years
    • $35 copay for hearing exams.
    Vision Services
    $0 copay for
    • one pair of eyeglasses or contact lenses after cataract surgery
  • glasses
  • contacts
  • lenses
  • frames
  • $0 to $35 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $35 copay for up to 1 routine eye exam(s) every year
    • $100 plan coverage limit for eye wear every two years.
    $35 copay for eye exams.
    $0 copay for eye wear.
    Physical Exams
    $0 copay for routine exams.
    Limited to 1 exam(s) every year.
    $0 copay for routine exams.
    Health/Wellness Education
    The plan covers the following health/wellness education benefits:
  • Written health education materials including Newsletters
  • Nutritional benefit
  • Health Club Membership/Fitness Classes
  • Nursing Hotline
  • Other Wellness Benefits
    • $0 copay for each Medicare-covered smoking cessation counseling session.
    $0 copay for each Medicare-covered HIV screening.
    HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.
    $0 copay for Health and Wellness services.
    Transportation
    This plan does not cover routine transportation.
    Acupuncture
    This plan does not cover Acupuncture.




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    .