TMSi 80/20 Plan BlueCard PPO Group 49992 Effective January 1, 2012
TMSi BlueCard PPO Effective January 1, 2012 BENEFIT
IN-NETWORK
OUT-OF-NETWORK
Benefit payments are based on the amount of the provider’s charge that Blue Cross and Blue Shield recognizes for payment of benefits. The allowed amount may vary depending upon the type provider and where services are received. Some services require a copay, coinsurance, calendar year deductible or deductible for each admission, visit or service.
HEALTH REIMBURSEMENT ARRANGEMENT (HRA) Health Reimbursement Arrangement: Your Health Plan works in conjunction with a Health Reimbursement Arrangement (HRA). An HRA is an account where your employer contributes a specific amount of money to be used by an employee for eligible expenses. Your HRA gives you the opportunity to manage your health care expenses in partnership with your employer. Amount allocated to your HRA account: Individual Coverage: $300 Individual + 1: $350 Family Coverage: $400 New Hire Provision: Allocations are prorated on a monthly basis. Change in Coverage Status: If there is a change in status from individual coverage to family coverage during the year, the HRA allocation will increase to the family coverage amount effective as of the effective date the status change based on a prorated schedule. If there is a change from family coverage to individual coverage, the HRA allocation will change to the greater of the individual coverage amount or the YTD HRA expense as of the effective date the status change. Roll-over Provision: Prior year unused HRA account balances will NOT roll over to the next plan year if you remain enrolled in the HRA option. HRA eligible expenses: HRA reimbursements are limited to all IRS eligible expenses as defined in IRS Code Section 213(d). If employment ends, you cannot take the balance of your account with you. If you elect COBRA coverage under the medical plan, you will continue to use your HRA in conjunction with your health plan. SUMMARY OF COST SHARING PROVISIONS (Includes Mental Health and Substance Abuse) Calendar Year Deductible For family coverage, once an individual member reaches the individual deductible amount, benefits will begin for that member.
Calendar Year Out-of-Pocket Maximum
Individual coverage: $750
Individual coverage: $1,500
For family coverage: $2,000
For family coverage: $4,000
Calendar year deductible amounts met innetwork will not apply to the out-of-network calendar year deductible. Individual coverage: $3,000 (including the Individual calendar year deductible)
Calendar year deductible amounts met outof-network will not apply to the in-network calendar year deductible. No out-of-pocket maximum.
For family coverage: $9,000 (including the family calendar year deductible) Other Covered Services, In-Network inpatient coinsurance and In-Network outpatient coinsurance are the only expenses applicable to the annual out-ofpocket maximum. After you reach Calendar Year Out-of-Pocket Maximum, applicable expenses covered at 100% for remainder of calendar year.
Annual Maximum Lifetime Maximum
$1,250,000 per member on all essential health benefits. Unlimited.
INPATIENT HOSPITAL AND PHYSICIAN BENEFITS (Includes Mental Health and Substance Abuse) Preadmission Certification required for all inpatient admissions (except maternity); notification within 48 hours for emergencies. Call 1 800 248-2342 (toll free) for precertification.
Deductibles and Copay Inpatient Facility Coverage (including maternity)
Subject to the calendar year deductible. No copay required. 80% coverage for semi-private room and board, intensive care units, general nursing services and usual hospital ancillaries.
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Subject to the calendar year deductible. 60% coverage for semi-private room and board, intensive care units, general nursing services and usual hospital ancillaries.
BENEFIT
IN-NETWORK OUTPATIENT HOSPITAL BENEFITS (Includes Mental Health and Substance Abuse)
Surgery Medical Emergency Accidental Injury Diagnostic Lab, X-ray, and Pathology Hemodialysis, IV Therapy Chemotherapy and Radiation Therapy
Covered at 80% of the allowed amount subject to the $50 facility copay. Covered at 80% of the allowed amount subject to the $150 facility copay. Covered at 80% of the allowed amount subject to the $100 facility copay. Covered at 80% of the allowed amount subject to the calendar year deductible. Covered at 80% of the allowed amount subject to the calendar year deductible.
OUT-OF-NETWORK
Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 80% of the allowed amount subject to the $150 facility copay. Covered at 80% of the allowed amount subject to the $100 facility copay. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible.
PHYSICIAN BENEFITS (Includes Mental Health and Substance Abuse) Primary Care Office Visits Specialist Office Visits Urgent Care Physician Services
Outpatient Consultations
Allergy Testing & Treatment Emergency Room Physician Fees Surgery and Anesthesia in the Physician’s Office Surgery and Anesthesia in an Outpatient Facility Inpatient Surgery and Anesthesia Inpatient Visits, Second Surgical Opinions and Inpatient Consultations Maternity Diagnostic X-rays and Lab Exams
Covered at 100% of the allowed amount subject to the $25 office visit copay. Covered at 100% of the allowed amount subject to the $30 physician copay. Covered at 100% of the allowed amount subject to the $30 physician copay. Mental Health and Substance Abuse Services: Covered at 100% of the allowed amount subject to the $25/$30 office visit copay. Covered at 100% of the allowed amount subject to the $25 copay for services by a primary care physician or $30 copay for services by a specialist. Covered at 100% of the allowed amount subject to the $30 physician copay. Covered at 100% of the allowed amount subject to the $30 physician copay. Covered at 80% of the allowed amount subject to the $25 physician copay. Covered at 80% of the allowed amount subject to the $30 physician copay. Covered at 80% of the allowed amount subject to the calendar year deductible. Covered at 80% of the allowed amount subject to the calendar year deductible. Covered at 80% of the allowed amount subject to the calendar year deductible. Covered at 80% of the allowed amount subject to the calendar year deductible.
Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible.
Covered at 60% of the allowed amount subject to the calendar year deductible.
Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 100% of the allowed amount subject to the $30 physician copay. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible.
Note: Nurse Practitioners and Physician’s Assistants are considered eligible providers.
ENHANCED PREVENTIVE CARE BENEFITS Inpatient Visits for Routine Newborn Care Well Child Care Exams
Routine Developmental Screening
Preventive Office Visits
Routine Immunizations (Age limitations apply to certain immunizations)
Covered at 100% of the allowed amount with no deductible or copay. Covered at 100% of the allowed amount with no deductible or copay. Includes 9 visits during the first two years of the child’s life and one visit each year thereafter through age 6. Covered at 100% with no deductible or copay; three exams between 9 months and 30 months of life Covered at 100% of the allowed amount with no deductible or copay. Limited to one exam every calendar year age 7 and over. Covered at 100% of the allowed amount with no deductible or copay.
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Not covered. Not covered.
Not covered
Not covered.
Not covered.
BENEFIT
IN-NETWORK
OUT-OF-NETWORK
Routine Pap Smears
Covered at 100% of the allowed amount with Not covered. no deductible or copay. Limited to one per year. Routine Human Papillomavirus (HPV) Covered at 100% of the allowed amount with Not covered. Testing no deductible or copay; one routine test every three calendar years for females ages 30 and over. Routine Chlamydia Screening Covered at 100% with no deductible or Not covered copay; one per calendar year for females ages 15-24 Routine Mammograms Covered at 100% of the allowed amount with Not covered. no deductible or copay. Limited to one exam for females between the ages of 35-39 and one per year for females age 40 and above. Routine Prostate Specific Antigen Covered at 100% of the allowed amount with Not covered. (includes digital rectal exam) no deductible or copay. Limited to one per year for males age 40 and over. Routine Colonoscopy Covered at 100% of the allowed amount with Not covered. no deductible or copay for members over 50 once every three calendar years. Other Routine Screening Covered at 100% of the allowed amount with Not covered. no deductible or copay. Includes the following: Urinalysis and CBC (when necessary), TB skin testing (when necessary) , Cholesterol Screening (once every year), Lipid panel (once every year), Hemocult (annually, ages 50 and over), Sigmoidoscopy (every 3 years, ages 50 and over). Note: In case of illness or family history of cancer, services generally are not considered preventive and may be covered by other plan provisions
ROUTINE VISION BENEFITS Eye Exam
Covered at 100% of the allowed amount Covered at 100% of the allowed amount subject to the $10 physician copay. subject to the $35 physician copay. Covered at 100% of the allowed amount up to a combined $200 maximum per person each calendar year.
(one eye exam per person every 12 months)
Lenses, Contact Lenses and Frames
PRESCRIPTION DRUG BENEFITS (Includes Mental Health and Substance Abuse) Prepaid Drug Card Preferred Rx Products • •
Non-maintenance – up to 30 day supply at retail Blue Cross Maintenance Drug List – up to a 60 day supply
Diabetic Supplies (copays apply) • Diabetic supplies are covered only through the Prescription Drug Card Program. •
Copays are combined for some products if purchased on the same day.
Participating Pharmacy: Prescription drugs will be covered at 100% subject to the following copays: Generic Drugs: $5 copay per prescription Preferred Brand Name Drugs: $35 copay per prescription Other Brand Name Drugs: $75 copay per prescription • • •
Insulin, insulin needles and syringes purchased on the same day will require only one copay. Blood glucose strips and lancets purchased on the same day will require only one copay. Glucose monitors will always require a separate copay.
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Non-Participating Pharmacy: There are no benefits available for prescription drugs purchased from a nonParticipating Pharmacy.
BENEFIT
IN-NETWORK
Mail Order Program
OUT-OF-NETWORK
Allows up to a 90 day supply through PrimeMail (1 800 391-1886); 100% after the following copayments : Generic Drugs: $10 copayment per prescription Preferred Brand Name Drugs: $70 copayment per prescription Other Brand Name Drugs: $150 copayment per prescription
Note: To view the most current Preferred Brand Drug List, visit our web site at www.bcbsal.com.
BENEFITS FOR OTHER COVERED SERVICES (Includes Mental Health and Substance Abuse) Ambulance Service Chiropractic Services $1,000 calendar year maximum per person
Approved Durable Medical Equipment (DME) Physical, Occupational and Speech Therapy
Covered at 80% subject to in network calendar year deductible Covered at 80% subject to calendar year deductible
Covered at 60% subject to calendar year deductible
Covered at 80% subject to calendar year deductible Covered at 80% subject to calendar year deductible
Covered at 60% subject to calendar year deductible
Limited to 30 combined visits for all therapies
HOME HEALTH AND HOSPICE BENEFITS (Includes Mental Health and Substance Abuse) Home Health and Hospice • Precertification required for visits by home health professionals outside Alabama • For precertification call 1 800 821-7231 • Limited to a 60 day maximum per year for Home Health and a 60 day maximum per year for Hospice Care.
Covered at 80% subject to calendar year deductible
Covered at 60% subject to calendar year deductible
HEALTH MANAGEMENT BENEFITS (Includes Mental Health and Substance Abuse) Individual Case Management
Coordinates care in event of catastrophic or lengthy illness or injury; For more information, please call 1-800-821-7231
Disease Management
Coordinates care for chronic conditions such as asthma, diabetes, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease.
Baby Yourself
Prenatal wellness program; For more information, please call 1 800 222-4379. You can also enroll online at behealthy.com. Useful Information to Maximize Benefits
• • • •
To maximize your benefits, always use In-network providers for services covered by your health benefit plan. To find In-Network providers, check a provider directory, provider finder web site (www.bcbsal.com) or call 1 800 810-BLUE (2583). In-network hospitals, physicians and other health care providers have a contract with a Blue Cross and/or Blue Shield Plan for furnishing health care services at a reduced price (examples: BlueCard PPO, PMD, Preferred Care). In-Network Pharmacies are pharmacies that participate with Blue Cross and Blue Shield of Alabama or Preferred Care Services, Inc. Out-of-network providers generally do not contract with Blue Cross and/or Blue Shield Plans. If you use Out-of-Network providers, you may be responsible for filing your own claims and paying the difference between the provider’s charge and the allowed amount. The allowed amount may be based on the negotiated rate payable to In-Network providers in the same area or the average charge for care in the area. Please be aware that providers/specialists may be listed in a PPO directory or provider finder web site, but not covered under this benefit plan. Please check your benefit booklet for more detailed coverage information.
This is not a contract, benefit booklet or a Summary Plan Description. Benefits are subject to the terms, limitations and conditions of the group contract. Please visit our web site, www.bcbsal.com. Group 49992 all divisions except 566 Revised 10-28-2011 JMR
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