Medicare Advantage Enhanced Benefits Fee Schedule: Revised November 11, 2016 • •

Inclusion of a fee schedule amount for an item doesn’t necessarily indicate coverage. Shaded cell indicates codes are no longer covered for the enhanced benefit. * 1.C – Individual Consideration

Note: If no fee is showing in the consecutive column that means the allowed amount remained the same.

BCBSM MEDICARE ADVANTAGE ENHANCED BENEFIT - FEE SCHEDULE Physician Services Procedure code

Location of service: F = Facility NF = Non-facility

Effective 07/01/2014 Allowed Amount

Effective 07/01/2015 Allowed Amount

Effective 07/01/2016 Allowed Amount

58300

F

$55.38

$54.94

$57.95

58300

NF

$74.58

$74.51

$77.52

80050

Same

$35.77

$35.77

$35.77

92015

F

$21.09

$20.70

$19.55

92015

NF

$21.47

$21.07

$19.90

99381

Same

$153.91

$154.90

$153.91

99382

Same

$160.36

$161.85

$160.85

99383

Same

$126.94

$127.57

$120.13

99384

Same

$143.52

$144.49

$135.76

99385

Same

$139.37

$140.36

$131.14

99386

Same

$160.84

$162.18

$152.47

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. BCBSM Medicare Advantage – Enhanced Benefits Fee Schedule

Page 1 of 9 Revised 11/11/16

BCBSM MEDICARE ADVANTAGE ENHANCED BENEFIT - FEE SCHEDULE Physician Services Procedure code

Location of service: F = Facility NF = Non-facility

Effective 07/01/2014 Allowed Amount

Effective 07/01/2015 Allowed Amount

Effective 07/01/2016 Allowed Amount

99387

Same

$174.78

$175.73

$165.26

99391

Same

$138.52

$139.01

$138.52

99392

Same

$147.94

$148.45

$147.94

99393

Same

$111.87

$112.14

$105.55

99394

Same

$122.42

$123.04

$115.86

99395

Same

$125.06

$126.06

$118.35

99396

Same

$133.34

$134.71

$126.17

99397

Same

$143.52

$144.87

$135.76

S0800

$1,088.17

$1,088.17

$1,088.17

S0800 (Bilateral)

$1,632.25

$1,632.25

$1,632.25

S4981

Same

$77.39

$77.39

$77.39

S4989

Same

$127.82

$127.82

$127.82

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. BCBSM Medicare Advantage – Enhanced Benefits Fee Schedule

WP 10472 NOV 16

Page 2 of 9 Revised 11/11/16 R056885

BCBSM MEDICARE ADVANTAGE ENHANCED BENEFIT – OTHER SERVICES Medical Supplies HCPCS code A4266

DMENsion Allowed Amount Effective 01/01/2015

DMENsion Allowed Amount Effective 01/01/2016

$34.20

$34.20

A4452

$0.09 $300 lifetime maximum

$0.09 $300 lifetime maximum

A4520

$0.80

$0.80

A4554

$0.36

$0.36

A4634

$35.78

$35.78

A4649

I.C.

I.C.

A6530

$21.00

$21.00

A6533

$22.93

$22.93

A6534

$57.33

$57.33

A6535

$57.94

$57.94

A6536

$65.18

$65.18

A6537

$69.40

$69.40

A6538

$84.00

$84.00

A6539

$77.85

$77.85

A6540

$87.50

$87.50

A6541

$92.25

$92.25

A6549

I.C.

I.C.

A9282

$100.00

$100.00

E0241

$14.39

$14.39

E0242

$121.52

$121.52

E0243

$59.65

$59.65

E0244

$17.50

$17.50

E0245

$39.00

$39.00

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. BCBSM Medicare Advantage – Enhanced Benefits Fee Schedule

WP 10472 NOV 16

Page 3 of 9 Revised 11/11/16 R056885

BCBSM MEDICARE ADVANTAGE ENHANCED BENEFIT – OTHER SERVICES Dental codes

BCBSM Fee Schedule Effective 01/01/2015

BCBSM Fee Schedule Effective 01/01/2016

D0120

SE MI Non SE MI

$43.00 $41.00

SE MI Non SE MI

$43.00 $41.00

D0140

SE MI Non SE MI

$70.00 $67.00

SE MI Non SE MI

$70.00 $67.00

D0150

SE MI Non SE MI

$74.00 $69.00

SE MI Non SE MI

$74.00 $69.00

D0160

SE MI Non SE MI

$110.00 $105.00

SE MI Non SE MI

$110.00 $105.00

D0220

SE MI Non SE MI

$24.00 $23.00

SE MI Non SE MI

$24.00 $23.00

D0230

SE MI Non SE MI

$17.00 $16.00

SE MI Non SE MI

$17.00 $16.00

D0270

SE MI Non SE MI

$24.00 $22.00

SE MI Non SE MI

$24.00 $22.00

D0272

SE MI Non SE MI

$37.00 $35.00

SE MI Non SE MI

$37.00 $35.00

D0273

SE MI Non SE MI

$45.00 $42.00

SE MI Non SE MI

$45.00 $42.00

D0274

SE MI Non SE MI

$53.00 $51.00

SE MI Non SE MI

$53.00 $51.00

D1110

SE MI Non SE MI

$76.00 $71.00

SE MI Non SE MI

$76.00 $71.00

D4910

SE MI Non SE MI

$145.00 $142.00

SE MI Non SE MI

$145.00 $142.00

D9940

SE MI Non SE MI

$585.00 $550.00

SE MI Non SE MI

$585.00 $550.00

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. BCBSM Medicare Advantage – Enhanced Benefits Fee Schedule

WP 10472 NOV 16

Page 4 of 9 Revised 11/11/16 R056885

(Continued)

BCBSM MEDICARE ADVANTAGE ENHANCED BENEFIT – OTHER SERVICES Drug Injections

Effective 11/01/2014

Effective 11/01/2015

J1050

$0.08

$0.07

J7300

$753.75

$753.78

J7302 (this code has been end-dated by CMS as of 12/31/2015)

$788.10 Effective 02/01/2015 $826.72

$826.71

J7303

$33.17

$33.17

J7304

$4.98

$4.99

J7306

IC

IC

J7307

$672.60

$786.94

J7297

-

$637.50

J7298

-

$826.71

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. BCBSM Medicare Advantage – Enhanced Benefits Fee Schedule

WP 10472 NOV 16

Page 5 of 9 Revised 11/11/16 R056885

BCBSM MEDICARE ADVANTAGE ENHANCED BENEFIT – OTHER SERVICES Home Infusion Therapy codes

Effective 01/01/2015

Effective 01/01/2016

99601

$128.37

$130.94

99602

$64.18

$65.46

S5497

$7.92

$8.08

S5498

$7.92

$8.08

S5501

$11.31

$11.54

S5502

$33.93

$34.61

S5517

$33.93

$34.61

S5518

$33.93

$34.61

S5520

$128.17

$130.73

S5521

$104.88

$106.98

S9061

$59.73

$60.92

S9325

$63.45

$64.72

S9326

$63.45

$64.72

S9327

$63.45

$64.72

S9328

$63.45

$64.72

S9329

$65.69

$67.00

S9330

$65.69

$67.00

S9331

$65.69

$67.00

S9336

$34.61

$35.30

S9338

$69.21

$70.59

S9346

$63.45

$64.72

S9347

$69.21

$70.59

S9348

$63.45

$70.59

S9351

$34.61

$35.30

S9355

$65.69

$67.00

S9357

$63.45

$64.72

S9359

$34.61

$35.30

S9361

63.45

$64.72

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. BCBSM Medicare Advantage – Enhanced Benefits Fee Schedule

WP 10472 NOV 16

Page 6 of 9 Revised 11/11/16 R056885

BCBSM MEDICARE ADVANTAGE ENHANCED BENEFIT – OTHER SERVICES Home Infusion Therapy codes

Effective 01/01/2015

Effective 01/01/2016

S9363

$15.00

$15.30

S9364

$196.11

$200.03

S9365

$196.11

$200.03

S9366

$196.11

$200.03

S9367

$230.71

$235.32

S9368

$230.71

$235.32

S9370

$8.74

$8.91

S9372

$8.74

$8.91

S9373

$40.38

$41.19

S9374

$40.38

$41.19

S9375

$40.38

$41.19

S9376

$40.38

$41.19

S9377

$40.38

$41.19

S9379

I.C.

I.C.

S9490

$63.45

$64.72

S9494

$63.45

$64.72

S9497

$63.45

$64.72

S9500

$63.45

$64.72

S9501

$63.45

$64.72

S9502

$63.45

$64.72

S9503

$63.45

$64.72

S9504

$63.45

$64.72

S9537

$7.92

$8.08

S9542

$8.49

$8.66

Private Duty Nursing codes

Effective 01/01/2015

Effective 07/01/2015

Effective 01/01/2016

S9123

$52.00

$53.04

$53.04

S9124

$45.00

$45.90

$45.90

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. BCBSM Medicare Advantage – Enhanced Benefits Fee Schedule

WP 10472 NOV 16

Page 7 of 9 Revised 11/11/16 R056885

BCBSM MEDICARE ADVANTAGE ENHANCED BENEFIT – OTHER SERVICES Hearing codes

Effective 01/01/2015

Effective 01/01/2016

S0618

$67.00

$67.00

V5010

$115.00

$118.00

V5020

$42.00

$43.00

V5030

$854.00

$854.00

V5040

$818.00

$818.00

V5050

$1,500.00

$1,500.00

V5060

$879.00

$879.00

V5070

$796.00

$796.00

V5080

$728.00

$728.00

V5100

$744.00

$744.00

V5120

$1,432.00

$1,432.00

V5130

$2,542.00

$2,542.00

V5140

$1,477.00

$1,477.00

V5150

$1,371.00

$1,371.00

V5170

$853.00

$853.00

V5180

$826.00

$826.00

V5190

$633.00

$633.00

V5210

$918.00

$918.00

V5220

$911.00

$911.00

V5230

$807.00

$807.00

V5242

$1,500.00

$1,500.00

V5243

$1,500.00

$1,500.00

V5244

$1,500.00

$1,500.00

V5245

$1,500.00

$1,500.00

V5246

$1,500.00

$1,500.00

V5247

$1,500.00

$1,500.00

V5248

$2,542.00

$2,542.00

V5249

$2,542.00

$2,542.00

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. BCBSM Medicare Advantage – Enhanced Benefits Fee Schedule

WP 10472 NOV 16

Page 8 of 9 Revised 11/11/16 R056885

BCBSM MEDICARE ADVANTAGE ENHANCED BENEFIT – OTHER SERVICES Hearing codes

Effective 01/01/2015

Effective 01/01/2016

V5250

$2,542.00

$2,542.00

V5251

$2,542.00

$2,542.00

V5252

$2,542.00

$2,542.00

V5253

$2,542.00

$2,542.00

V5254

$1,500.00

$1,500.00

V5255

$1,500.00

$1,500.00

V5256

$1,500.00

$1,500.00

V5257

$1,500.00

$1,500.00

V5258

$2,542.00

$2,542.00

V5259

$2,542.00

$2,542.00

V5260

$2,542.00

$2,542.00

V5261

$2,542.00

$2,542.00

V5299

I.C.

I.C.

Provider Delivered Care Management 98961 98962 98966 98966 98967 98967 98968 98968 99487 99489 G9001 G9002 G9007 G9008

Location of service: F = Facility NF = Non-facility Same Same F NF F NF F NF Same Same Same Same Same Same

Effective 01/01/2015 $16.17 $12.02 $16.59 $16.59 $31.93 $31.93 $47.28 $47.28 $89.97 $45.17 $129.37 $64.69 $30.00 $50.00

S0257

Same

$30.00

Effective 07/01/2015 $16.29 $12.11 $15.05 $16.73 $30.51 $32.20 $46.41 $47.65 $99.26 $49.84 $130.41 $65.21 $33.10 $50.15 $33.00

Effective 07/01/2016 $16.29 $12.11 $15.05 $16.73 $30.51 $32.20 $46.41 $47.65 $99.26 $49.84 $130.41 $65.21 $33.10 $50.15 $33.00

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. BCBSM Medicare Advantage – Enhanced Benefits Fee Schedule

WP 10472 NOV 16

Page 9 of 9 Revised 11/11/16 R056885