BCNEPA - Our Health Plans - Individual Health Plans - Blue Cross Blue Shield 65-Special Benefits

Service	This Policy Pays	For Eligible Benefits you pay
Inpatient hospital services - semi-private room and board	$1024 Part A deductible per benefit period	Nothing
Miscellaneous hospital services and supplies, such as drugs, x-rays, lab tests and operating room	$256 coinsurance per day 61st to 90th day per benefit period	Nothing
	$512 coinsurance per day 91st to 150th day when you use your 60 Medicare nonrenewable lifetime reserve days	Nothing
	365 additional days (lifetime maximum) except for non-member hospitals when Blue Cross pays 90% of reasonable charges	Nothing, except for non-member hospitals
Blood	Payment of blood deductible (equal to cost for first 3 pints) and 20% of reasonable charges after Part B $135 deductible	Nothing
Outpatient hospital services	$135 deductible and 20% of reasonable charge	Nothing
Skilled nursing facility care	$128 coinsurance per day 21st to 100th day per benefit period	Nothing
	Nothing beyond payment of the Medicare coinsurance for 100 days per benefit period	All skilled nursing facility charges in excess of 100 days per benefit period
Private rooms	An allowance equal to the most prevalent charge for semi-private accommodations in that hospital	Difference between private and semi-private accommodations
In-hospital private nurses	No coverage
Home health services	No coverage

This summary is an abridged overview of the benefits covered by this plan. It highlights general features and is not intended to be a substitute for the terms, provisions, limitations and conditions imposed by the controlling Blue Cross of Northeastern Pennsylvania and Highmark Blue Shield agreement(s). For more information regarding your specific coverage needs, please call your Group Administrator or contact BlueCare Senior Representatives at 1-800-829-8599 or (TTY) 1-866-280-0486.

About Us | Careers | News Center | Notice of Privacy Practice | Privacy & Security Statement | Terms & Conditions
Serving Bradford, Carbon, Clinton, Lackawanna, Luzerne, Lycoming, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne and Wyoming Counties.
Copyright © 2008, Blue Cross of Northeastern Pennsylvania is an Independent
Licensee of the BlueCross BlueShield Association. All rights reserved.

BlueCare® Senior (Summary of Supplemental Benefits)

BlueCare^® Senior
(Summary of Supplemental Benefits)