Doctors in Red Bank Tn Blue Advantage Sapphire

2022 Medicare Advantage Plan Details Medicare Plan Name: BlueAdvantage Sapphire (PPO) Location: Sullivan, Tennessee Plan ID: H7917 - 031 - 0 Click to see other plans Member Services: 1-800-831-2583 TTY users 711 — Enrollment Options — Medicare Contact Information: 1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048

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Email a copy of the BlueAdvantage Sapphire (PPO) benefit details — Medicare Plan Features — Monthly Premium: $0.00 (see Plan Premium Details below) Annual Deductible: $0 Annual Initial Coverage Limit (ICL): $4,430 Health Plan Type: Local PPO Maximum Out-of-Pocket Limit for Parts A & B (MOOP): $5,100 Additional Gap Coverage? Yes, some additional gap coverage. Total Number of Formulary Drugs: 3,702 drugs Browse the BlueAdvantage Sapphire (PPO) Formulary This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers.  This plan offers select insulin at a $35 copay. Learn more. Formulary Drug Details: Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 • Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase: $1.00 $10.00 $42.00 $92.00 33% • Number of Drugs per
  Tier: 603 1285 423 562 829 Plan's Pharmacy Search: http://bcbstmedicare.com Plan Offers Mail Order? Yes Medicare Plan Pharmacy Numbers: BIN: 610014   PCN: MEDDPRIME Number of Members enrolled in this plan in Sullivan, Tennessee: 5,470 members Number of Members enrolled in this plan in Tennessee: 12,752 members Number of Members enrolled in this plan in (H7917 - 031): 12,775 members Plan's Summary Star Rating: 4.5 out of 5 Stars. • Customer Service Rating: 4 out of 5 Stars. • Member Experience Rating: 5 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split as Follows: ❔
Total
Premium Part C
Premium Part D Base
Premium Part D Supplemental
Premium $0.00 $0.00 $0.00 $0.00 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 Total Monthly Premium with LIS (Parts C & D): $0.00 $0.00 $0.00 $0.00

— Plan Health Benefits — ** Base Plan ** Premium • Health plan premium: $0 • Drug plan premium: $0 • You must continue to pay your Part B premium. • Part B premium reduction: No Deductible • Health plan deductible: $0 • Other health plan deductibles: In-network: No • Drug plan deductible: No annual deductible Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) • $11 Optional supplemental benefits • No Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? • In-network: No Doctor visits • Primary In-network: $10 copay per visit • Primary Out-of-network: 50% coinsurance per visit • Specialist In-network: $35 copay per visit • Specialist Out-of-network: 50% coinsurance per visit Diagnostic procedures/lab services/imaging • Diagnostic tests and procedures In-network: $10-100 copay (authorization required) • Diagnostic tests and procedures Out-of-network: 50% coinsurance (authorization required) • Lab services In-network: $0-40 copay or 20% coinsurance (authorization required) • Lab services Out-of-network: 50% coinsurance (authorization required) • Diagnostic radiology services (e.g., MRI) In-network: $225 copay (authorization required) • Diagnostic radiology services (e.g., MRI) Out-of-network: 50% coinsurance (authorization required) • Outpatient x-rays In-network: $10-50 copay (authorization required) • Outpatient x-rays Out-of-network: 50% coinsurance (authorization required) Emergency care/Urgent care • Emergency: $90 copay per visit (always covered) • Urgent care: $65 copay per visit (always covered) Inpatient hospital coverage • In-network: $300 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 91 and beyond (authorization required) • Out-of-network: 50% per stay (authorization required) Outpatient hospital coverage • In-network: $300 copay per visit (authorization required) • Out-of-network: 50% coinsurance per visit (authorization required) Skilled Nursing Facility • In-network: $0 per day for days 1 through 20
$188 per day for days 21 through 100 (authorization required) • Out-of-network: 50% per stay (authorization required) Preventive care • In-network: $0 copay • Out-of-network: 50% coinsurance Ground ambulance • In-network: $250 copay • Out-of-network: $250 copay Rehabilitation services • Occupational therapy visit In-network: $35 copay (authorization required) • Occupational therapy visit Out-of-network: 50% coinsurance (authorization required) • Physical therapy and speech and language therapy visit In-network: $35 copay (authorization required) • Physical therapy and speech and language therapy visit Out-of-network: 50% coinsurance (authorization required) Mental health services • Inpatient hospital - psychiatric In-network: $300 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization required) • Inpatient hospital - psychiatric Out-of-network: 50% per stay (authorization required) • Outpatient group therapy visit with a psychiatrist In-network: $20 copay (authorization required) • Outpatient group therapy visit with a psychiatrist Out-of-network: 50% coinsurance (authorization required) • Outpatient individual therapy visit with a psychiatrist In-network: $30 copay (authorization required) • Outpatient individual therapy visit with a psychiatrist Out-of-network: 50% coinsurance (authorization required) • Outpatient group therapy visit In-network: $20 copay (authorization required) • Outpatient group therapy visit Out-of-network: 50% coinsurance (authorization required) • Outpatient individual therapy visit In-network: $30 copay (authorization required) • Outpatient individual therapy visit Out-of-network: 50% coinsurance (authorization required) Opioid treatment program services • In-network: $20.00-$30.00 copay (authorization required) • Out-of-network: 50% coinsurance (authorization required) Medical equipment/supplies • Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item (authorization required) • Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 50% coinsurance per item (authorization required) • Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required) • Prosthetics (e.g., braces, artificial limbs) Out-of-network: 50% coinsurance per item (authorization required) • Diabetes supplies In-network: $0 copay (authorization required) • Diabetes supplies Out-of-network: 50% coinsurance per item (authorization required) Dialysis • 20% coinsurance Hearing • Hearing exam In-network: $10 copay • Hearing exam Out-of-network: $10 copay • Fitting/evaluation In-network: $0 copay • Fitting/evaluation Out-of-network: $0 copay • Hearing aids In-network: $599-899 copay (limits apply) • Hearing aids Out-of-network: $599-899 copay (limits apply) Preventive dental • Oral exam In-network: $0 copay (limits apply) • Oral exam Out-of-network: 50% coinsurance (limits apply) • Cleaning In-network: $0 copay (limits apply) • Cleaning Out-of-network: 50% coinsurance (limits apply) • Fluoride treatment: Not covered • Dental x-ray(s) In-network: $0 copay (limits apply) • Dental x-ray(s) Out-of-network: 50% coinsurance (limits apply) Comprehensive dental • Non-routine services In-network: $0 copay (limits apply) • Non-routine services Out-of-network: 50% coinsurance (limits apply) • Diagnostic services In-network: $0 copay (limits apply) • Diagnostic services Out-of-network: 50% coinsurance (limits apply) • Restorative services In-network: $0 copay (limits apply) • Restorative services Out-of-network: 50% coinsurance (limits apply) • Endodontics In-network: $0 copay (limits apply) • Endodontics Out-of-network: 50% coinsurance (limits apply) • Periodontics In-network: $0 copay (limits apply) • Periodontics Out-of-network: 50% coinsurance (limits apply) • Extractions In-network: $0 copay (limits apply) • Extractions Out-of-network: 50% coinsurance (limits apply) • Prosthodontics, other oral/maxillofacial surgery, other services In-network: $0 copay (limits apply) • Prosthodontics, other oral/maxillofacial surgery, other services Out-of-network: 50% coinsurance (limits apply) Vision • Routine eye exam In-network: $35 copay (limits apply) • Routine eye exam Out-of-network: $35 copay (limits apply) • Other: Not covered • Contact lenses In-network: $0 copay (limits apply) • Contact lenses Out-of-network: $0 copay (limits apply) • Eyeglasses (frames and lenses) In-network: $0 copay (limits apply) • Eyeglasses (frames and lenses) Out-of-network: $0 copay (limits apply) • Eyeglass frames: Not covered • Eyeglass lenses: Not covered • Upgrades: Not covered Medically-approved non-opioid pain management services • Chiropractic services: Not covered • Acupuncture: Not covered • Therapeutic Massage: Not covered • Alternative Therapies: Not covered More benefits • Over-the-counter drug benefits: Not covered • Meals for short duration: Some coverage • Annual physical exams: Some coverage • Telehealth: Some coverage • WorldWide emergency transportation: Some coverage • WorldWide emergency coverage: Some coverage • WorldWide emergency urgent care: Some coverage • Fitness Benefit: Some coverage • In-Home Support Services: Not covered • Bathroom Safety Devices: Not covered • Health Education: Some coverage • In-Home Safety Assessment: Not covered • Personal Emergency Response System (PERS): Not covered • Medical Nutrition Therapy (MNT): Not covered • Post discharge In-Home Medication Reconciliation: Not covered • Re-admission Prevention: Not covered • Wigs for Hair Loss Related to Chemotherapy: Not covered • Weight Management Programs: Not covered • Adult Day Health Services: Not covered • Nutritional/Dietary Benefit: Some coverage • Home-Based Palliative Care: Not covered • Support for Caregivers of Enrollees: Not covered • Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered • Enhanced Disease Management: Some coverage • Telemonitoring Services: Some coverage • Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage • Counseling Services: Not covered Wellness programs (e.g., fitness, nursing hotline) • Covered Transportation • Not covered Foot care (podiatry services) • Foot exams and treatment In-network: $35 copay • Foot exams and treatment Out-of-network: 50% coinsurance • Routine foot care: Not covered Medicare Part B drugs • Chemotherapy In-network: 20% coinsurance (authorization required) • Chemotherapy Out-of-network: 50% coinsurance (authorization required) • Other Part B drugs In-network: 20% coinsurance (authorization required) • Other Part B drugs Out-of-network: 50% coinsurance (authorization required)

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Source: https://q1medicare.com/MedicareAdvantage-PartC-MedicareHealthPlanBenefits.php?countyCode=47163&state=TN&contractId=H7917&planId=031&plan=BlueAdvantage%20Sapphire%20(PPO)

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