Benefits At-A-Glance
| Medicare Coverage | Blue Care Network 65 Coverage | |
| Preventative Services | ||
| Health Maintenance Exam | Not Covered | Covered - 100% |
| Annual Gynecological Exam | Not Covered | Covered - 100% |
| Pap Smear Screening - laboratory services only | Covered - 80% of approved amount after Part B deductible, one every 3 years | Covers Medicare deductible and coinsurance |
| Well-Baby and Child Care | Not Covered | Covered - 100% |
| Flu Shots and Pneumonia Vaccines | Covered - 100% of approved amount | Covered in full by Medicare |
| Hepatitis B Vaccines - for those at risk of contracting the disease | Covered - 80% of approved amount after Part B deductible | Not Covered |
| Mammography | ||
| Mammography Screening | Covered - 80% of approved amount after Part B deductible, one every 24 months | Covers Medicare deductible and coinsurance |
| Physician Office Services | ||
| Office Visits | Covered - 80% of approved amount after Part B deductible | Covers Medicare deductible and coinsurance |
| Consulting Specialist Care - when referred | Covered - 80% of approved amount after Part B deductible | Covers Medicare deductible and coinsurance |
| Emergency Medical Care | ||
| Hospital Emergency Room (professional services) - must be medically necessary | Covered - 80% of approved amount after Part B deductible | Covers Medicare deductible and coinsurance |
| Physician's Office | Covered - 80% of approved amount after Part B deductible | Covers Medicare deductible and coinsurance |
| Urgent Care Center | Covered - 80% of approved amount after Part B deductible | Covers Medicare deductible and coinsurance |
| Ambulance Services - must be medically necessary | Covered - 80% of approved amount after Part B deductible | |
| Clinical Laboratory Services | ||
| Laboratory and Pathology Tests - used in the diagnosis and treatment of an illness or injury | Covered - 100% of approved amount | Covered in full by Medicare |
| Diagnostic Tests and X-rays | Covered - 80% of approved amount after Part B deductible | Covers Medicare deductible and coinsurance |
| Hospital Care | ||
| Semi-Private Room, Inpatient Physician Care, General Nursing Care, Hospital Services and Supplies | ||
| • Days 1-60 | Covered - Less Medicare Part A deductible | Covers Medicare deductible |
| • Days 61-90 | Covered - Less Medicare Part A daily coinsurance | Covers Medicare daily coinsurance |
| • Lifetime Reserve Days (60 days) | Covered - Less Medicare Part A daily coinsurance | Covers Medicare daily coinsurance |
| • Additional Days | Not Covered | Covered - 100% of approved amount, unlimited days |
| Chemotherapy | Covered for administration and drugs - 80% of approved amount after deductible; must meet Medicare criteria | Covers Medicare deductible and coinsurance. Pays chemotherapy drugs which Medicare does not cover; must meet BCN criteria for payment. |
| Alternatives to Hospital Care | ||
| Skilled Nursing Facility Care | ||
| • Days 1-20 | Covered - 100% of approved amount | Covered in full by Medicare |
| • Days 21-100 | Covered - Less Medicare daily coinsurance | Covers Medicare coinsurance |
| • Days 101 and after | Not Covered | Not Covered |
| Hospice Care | Covered - 100% of approved amount, less small coinsurance amounts for outpatient drugs and inpatient respite care | Not Covered |
| Home Health Care - medically necessary | Covered - 100% of approved amount | Covered in full by Medicare |
| Surgical Services Provided by a Physician | ||
| Surgery - includes all related surgical services, anesthesia and surgical assistance | Covered - 80% of approved amount after Part B deductible | Covers Medicare deductible and coinsurance |
| Human Organ Transplants | Note: Payment is based on medical necessity and must be rendered in an approved facility. | |
| Heart and Liver | Covered - Less Medicare deductible and coinsurance | Covers Medicare deductible and coinsurance, subject to medical criteria |
| Lung and Heart-lung | Covered - Less Medicare deductible and coinsurance | Covers Medicare deductible and coinsurance, subject to medical criteria |
| Pancreas | Covered when performed simultaneously with or after a kidney transplant - Less Medicare deductible and coinsurance | Covers Medicare deductible and coinsurance, subject to medical criteria |
| Cornea | Covered - Less Medicare deductible and coinsurance | Covers Medicare deductible and coinsurance, subject to medical criteria |
| Bone Marrow and Kidney | Covered - Less Medicare deductible and coinsurance | Covers Medicare deductible and coinsurance, subject to medical criteria |
| Mental Health Care | ||
| Inpatient Mental Health Care in psychiatric hospital | ||
| • Days 1-190 lifetime | Covered - Less Medicare deductible and coinsurance Note: In most cases, psychiatric care in general (as opposed to psychiatric) hospitals is not subject to the 190-day limit. |
Covers Medicare deductible and coinsurance |
| • Additional days after 190 lifetime days are used | Not Covered | Not Covered |
| Outpatient Mental Health Care | Covered - 50% of approved amount after Part B deductible for therapeutic services. Diagnostic services are covered at 80% of approved amount after Part B deductible. | Covers Medicare deductible and coinsurance |
| Other Services | ||
| Allergy Testing and Therapy - with approved diagnosis | Covered - 80% of approved amount after Part B deductible | Covers Medicare deductible and coinsurance |
| Chiropractic Spinal Manipulation - must be medically necessary | Covered when medically necessary - 80% of approved amount after Part B deductible | Not Covered |
| Outpatient Physical, Speech and Occupational Therapy | Covered - 80% of approved amount after Part B deductible is met Note: Services of independent physical or occupational therapist subject to annual dollar limit. |
Covers Medicare deductible and coinsurance, limited to 60 treatments per condition per year |
| Durable Medical Equipment | Covered - 80% of approved amount after Part B deductible | Covers Medicare deductible and coinsurance |
| Prosthetic Appliances | Covered - 80% of approved amount after Part B deductible | Covers Medicare deductible and coinsurance |
| Private Duty Nursing and Custodial Care | Not Covered | Not Covered |
| Prescription Drugs | Not Covered | Covered - $10 copay for generic drugs and $40 copay for brand name drugs. Contraceptives excluded. |
| Mail Order Prescription Drugs | Not Covered | Provides benefits to the Prescription Drug Plan for a 90 day supply of prescribed medications, with a $10 copay for generic drugs and $40 copay for brand name drugs for each 90 day prescription or refill. |
| Oral Cancer Drugs | Approved drugs are covered | Covered in full by Medicare |
| Foreign Travel | ||
| Hospital Services | Not Covered, except for inpatient hospital services in Canada or Mexico in rare situations | Not Covered |
| Physician Services | Not Covered, except for services rendered in Canada or Mexico in connection with a covered inpatient stay | Not Covered |
SERVICES MUST BE PROVIDED OR ARRANGED BY THE MEMBER'S PRIMARY CARE PHYSICIAN OR HEALTH PLAN
This is intended as an easy-to-read summary. It is not a contract. An official description of benefits is contained in applicable Blue Care Network certificates and riders. Payment amounts are based on the Blue Care Network approved amount, less any applicable deductible and/or copay amounts required by the plan. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan. Services must be provided or arranged by member's primary care physician or health plan.
