Agreement - Blue Cross Blue Shield - Self Fund Medical Insurance for CIty Employees for 2019

Home Browse Search

Your Summary of Benefits O PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology, geriatrics or any other Network provider as allowed by the plan. O SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice. O Live Health Online (LHO) is covered at the PCP costshare. O Certain diabetic and asthmatic supplies, except diabetic test strips, have no deductible/copayment/coinsurance up to the maximum allowable amount at network pharmacies, o Benefit period = calendar year O Prosthetic limbs are unlimited and do not apply to the Plan Lifetime Maximum. O Mammograms (Diagnostic) are no copayment/coinsurance in Network office and outpatient facility settings. O Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity. O Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are no deductible/coinsurance up to the maximum allowable amount. O Private Duty Nursing — limited to 82 visits/Calendar Year and 164 visits/lifetime. Elective abortions not covered unless otherwise noted in your Certificate of Coverage.. 1 These covered services are not subject to the deductible/copayment if you have a flat dollar oopayment and if rendered without an office visit. 2 We encourage you to review the Schedule of Benefits for limitations. 3 Kidney and Comea are treated the same as any other illness and subject to the medical benefits. 4 Rx non -network diabeticlasthmatic supplies not covered except diabetic test strips. Precertif!cation: Members are encouraged to always obtain prior approval when using non -network providers. Precertification will help the member know if the services are considered not medically necessary. Pre•exlsting Excluslon Period: none This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This benefit overview is for illustrative purposes and some content may be pending Indiana Department of Insurance approval. This summary of benefits is intended to be a brief outline of coverage. The enfire provisions of benefits and exclusions are contained in the Group Contract, Certificate, and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail. By signing this Summary of Benefits, I agree to the benefits for the product selected as of the effective date indicated.