2020 BlueCare Plus Plan Details


In-Network Benefits and Plan Information

Plan Name

Plan Type

Monthly Premium

Low Income Subsidy (Extra Help)

Out-of-Pocket Maximum

Plan Benefits

Plan Rating

BlueCare Plus (HMO SNP)

Health Maintenance Organization (HMO)

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View Plan Premiums

$6,700

Summary of Benefits

BlueCarePlus Plan Rating

Provider Directory Is your doctor covered in our network?
Pharmacy and Prescription Drug Benefits

Pharmacy Directory

Prescription Drug List
Click on the Prescription Drug List link below to see if your drugs are covered.
2020 Prescription Drug List
Prescription Drug List Archive

Other Forms & Documents
Part D Prior Authorization Criteria
Transition Policy
Part D Out of Network Coverage
Step Therapy Criteria
Quality Assurance Policy

Retail and Mail Order Pharmacy
Cost Tier 1 - Preferred Generic Drugs
Cost Tier 2 - Generic Drugs
Cost Tier 3 - Preferred Brand Drugs and includes some Generic Drugs
Cost Tier 4 - Non-preferred Drugs and includes some Generic Drugs
Cost Tier 5 - Specialty Drugs that includes some Brand and Generic Drugs

Saving at the Pharmacy
BlueCross BlueShield of Tennessee often works with suppliers to offer free and discounted necessities to help make staying healthy more affordable. To find a participating pharmacy, check your Pharmacy directory.

Blood Sugar Monitors
Do you need a blood sugar monitor?
We offer free blood glucose monitors for our members. The program is easy to use, just click and print the coupon for either a free Ascensia® or OneTouch® glucose monitor and take it to your pharmacy.

Additional Benefits*

Dental
Up to $5,000 for routine and comprehensive dental services combined.

Hearing Services
Up to $2,500 for a routine hearing exam, hearing aid fitting/evaluation, and hearing aid, combined.

Vision Care
$0 copay for each routine exam every year. Up to $325 towards glasses or contacts.

Over-the-Counter (OTC) Catalog
Up to $300 per quarter for items listed in the OTC catalog

Transportation (Southeastrans)
Plan covers 100 one-way (50 round-trip), non-emergent rides each year to your covered appointments. Contact Customer Service for more information about your transportation benefits.

Chiropractic Services
Up to 20 routine visits

Meals
Up to 2 meals per day for up to 7 days following discharge from an inpatient hospital or skilled nursing facility stay

Personal Emergency Response System
The personal emergency response system provides help in emergency situations. The medical alert service comes with an installed in-home communication device and a wearable button.

Telehealth
The plan utilizes a telehealth vendor that offers telephonic and web-based access to a licensed physician for the consultation, diagnosis and/or treatment of certain non-emergent conditions when the member’s treating physician is not available (e.g., after hours or weekends).

Additional Resources

Important Forms and Documents
Evidence of Coverage 2020 (EOC)
Annual Notice of Changes 2020 (ANOC)
Multi-Language Insert
Appointment of Representative Form
Best Available Evidence (BAE) Policy
Notices and Disclaimers

Member Rights

Coverage Decisions, Appeals & Complaints

2020 BlueCare Plus Choice (HMO SNP)SM Plan Details

BlueCare Plus Choice members also get the following benefits, depending on their qualifications:

Plan Materials

2020 BlueCare Plus Choice Summary of Benefits

2020 BlueCare Plus Choice Evidence of Coverage

Additional Benefits
Service and Benefit Limit Group 1 Group 2 Group 3
Nursing facility care X Short-term only (up to 90 days) Short-term only (up to 90 days)
Community-based residential alternatives (CBRA) X (Specified CBRA services and levels of reimbursement only. See below)1
Personal care visits (up to 2 visits per day at intervals of no less than 4 hours between visits) X X
Attendant care (up to 1080 hours per calendar year; up to 1400 hours per full calendar year only for persons who require covered assistance with household chores or errands in addition to hands-on assistance with self-care tasks) X X
Home-delivered meals (up to 1 meal per day) X X
Personal Emergency Response Systems (PERS) X X
Adult day care (up to 2080 hours per calendar year) X X
In-home respite care (up to 216 hours per calendar year) X X
In-patient respite care (up to 9 days per calendar year) X X
Assistive technology (up to $900 per calendar year) X X
Minor home modifications (up to $6,000 per project; $10,000 per calendar year; and $20,000 per lifetime) X X
Pest Control (up to 9 units per calendar year) X X

1CBRAs for which Group 3 members are eligible include only: Assisted Care Living Facility services, Community Living Supports 1 (CLS1), and Community Living Supports-Family Model 1 (CLS-FM1)

*These supplemental benefits, are not covered by Medicare and Medicaid, they are covered by BlueCare Plus

 

This page was updated on October 1, 2019