Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, give you other plans' brochures and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.  For information on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee, and one or more eligible family members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family.  You may change your enrollment 31 days before to 60 days after that event.  The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member.  When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment. 

Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26^th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.      

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage from a state that recognizes common-law marriages) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to a Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims processed according to the 2024 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2023 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment, or
• You are a family member no longer eligible for coverage.

Any person covered under the 31-day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31-day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC).

If you are an enrollee and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof.  In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment.  This is the case even when the court has ordered your former spouse to provide health coverage for you.  However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC).  If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices.  You can also visit OPM’s website at https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn 26.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must  contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-662-6667 or visit our website at www.bcbsm.com.

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment or if you need replacement cards, call us at 800-662-6667 or write to us at Blue Care Network of Michigan, P.O. Box 5043, Southfield, MI 48086-5043. You may also request replacement cards through our website at www.bcbsm.com.

You get care from “Plan providers” and “Plan facilities.”  You will only pay copayments, deductibles, and/or coinsurance, if you use our point-of-service program, you can also get care from non-Plan providers but it will cost you more.  If you use our Open Access program you can receive covered services from a participating provider without a required referral from your primary care provider or by another participating provider in the network.

FEHB Carriers must have clauses in their in-network (participating) provider agreements.  These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount.  If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law.  We credential Plan providers according to national standards.

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area. 

We list Plan providers in our provider directory, which we update periodically. You can also find Plan providers in your area on our website at www.bcbsm.com/find-a-doctor.

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

This plan provides Care Coordinators for complex conditions and can be reached at 800-662-6667 for assistance.

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in our provider directory, which we update periodically. You can also find Plan facilities in your area on our website at www.bcbsm.com/find-a-doctor.

It depends on the type of care you need.  First, you and each family member must choose a primary care provider.  This decision is important since your primary care provider provides or arranges for most of your health care. 

Your primary care provider can be a family or general practitioner, an internist or, for your children, a pediatrician. Your primary care provider will provide most of your healthcare or give you a referral to see a specialist.

If you want to change primary care provider or if your primary care provider leaves the Plan, call us. We will help you select a new one. You may also change primary care providers through our website at www.bcbsm.com/find-a-doctor.

Your primary care provider will refer you to a specialist for needed care. When you receive a referral from your primary care provider, you must return to the primary care provider after the consultation, unless your primary care provider authorizes a certain number of visits without additional referrals. The primary care provider must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care provider gives you a referral. However, female members may self refer to a gynecologist or obstetrician-gynecologist for their annual well-woman exams and routine services.

Here are some other things you should know about specialty care:

• If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care provider will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals.

Your primary care provider will create your treatment plan. The physician may have to get an authorization or approval from us beforehand.  If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. 

If they decide to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

• If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:

• terminate our contract with your specialist for other than cause;
• drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
• reduce our service area and you enroll in another FEHB plan

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Your Plan primary care provider or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Customer Service department immediately at 800-662-6667. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

Since your primary care provider arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services.

Your primary care doctor must get prior approval from Blue Care Network of Michigan for certain services. Failure to do so may result in no coverage of services. 

Your primary care provider has authority to refer you for most services. For certain services, however, your physician must obtain prior approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. Services that require prior authorization include, but are not limited to:  

• Reconstructive surgery
• Transplants
• Certain infertility treatments
• Nursing home care
• Physical/occupational/speech therapy
• Cardiac/pulmonary rehabilitation
• Surgical treatment of morbid obesity
• Growth hormone therapy
• Genetic testing and treatment
• Inpatient admissions
• Diagnosis, evaluation and treatment for autism spectrum disorders
• Chiropractic care
• Dental services
• Durable medical equipment
• Orthotics and prosthetics
• Orthognathic surgery
• Pain management
• High tech radiology procedures
• TMJ treatment
• Nonemergency ambulance

First, your physician, your hospital, you, or your representative, must call us at 800-392-2512 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

• enrollee’s name and Plan identification number;
• patient’s name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay.

For non-urgent care claims, we will  tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization.  We will make our decision within 15 days of receipt of the pre-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours.  If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-662-6667. You may also call OPM’s Health Insurance 3 at 202- 606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-662-6667. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

A concurrent care claim involves care provided over a period of time or over a number of treatments.  We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends.  If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect. 

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. 

You do not need precertification of a maternity admission for a routine delivery.  However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days.  Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

Your primary care provider provides your care or manages it through a referral process. Only your primary care provider can refer you to specialist care. If your primary care provider doesn't refer you, you are responsible for the charges.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 800-662-6667.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask your provider for more information.
   
   You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.
   
   If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.
3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.  We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: In the High Option Plan, when you see your primary care provider you pay a copayment of $15 per office visit and when you go to the hospital emergency room you pay $100 per visit for emergency care.

Coinsurance is the percentage of our allowance that you must pay for your care.

Example: In our Plan, you pay 50% of our allowance for durable medical equipment and prosthetics and orthotics.

 You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

After your out-of-pocket expenses, including any applicable deductibles, copayments and coinsurance total $6,350 for Self Only, or $12,700 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. The maximum annual limitation on cost sharing listed under Self Only of $6,350 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Example Scenario:  Your plan has a $6,350 Self Only maximum out-of-pocket limit and a $12,700 Self Plus One or Self and Family maximum out-of-pocket limit.   If you or one of your eligible family members has out-of-pocket qualified medical expenses of $6,350 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan.  With a Self and Family enrollment out-of-pocket maximum of $12,700, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $6,350 for the calendar year before their qualified medical expenses will begin to be covered in full. 

However, copayments and coinsurance, if applicable for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services: 

• Dental discount benefits
• Eyeglasses or contact lenses 
• Premiums paid 
• Balance bills charged 
• Health Care Services not covered by Blue Care Network of Michigan. This includes services that exceed benefit limits such as day and limit visits 
• Expenses from utilizing out-of-network providers 

Be sure to keep accurate records and receipts of your copayments and coinsurance to ensure the plan’s calculation of your out-of-pocket maximum is reflected accurately.

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services.

A surprise bill is an unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from surprise bills. 

In addition, your health plan adopts and complies with the surprise billing laws of Michigan and NSA.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to bcbsm.com or contact the health plan at 800-662-6667.

• Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

• No deductible
• Out-of-pocket maximum
  There is an out-of-pocket maximum of $6,350 for Self Only, $12,700 for Self Plus One or $12,700 per Self and Family. Medical and prescription copayments and coinsurance count toward this annual out-of-pocket maximum.
• Coinsurance
  50% of the BCN approved amount for durable medical equipment; prosthetics/orthotics; infertility; orthognathic surgery; reduction mammoplasty and male mastectomy
• Office visits
  You pay $15 for visits to your primary care provider
  You pay $25 for visits to a specialist
• Adult and child preventive care (physicals and screenings)
  Covered in full
• Maternity care
  Covered in full
• Emergency care
  $100 copayment
• Ambulance
  Covered in full
• Prescription drugs 
  30-day retail and mail order: $10 for Tier 1 (mostly generic drugs); $30 for Tier 2 (preferred brand-name drugs); $60 for Tier 3 (nonpreferred brand-name drugs). 
• 90-day retail and mail order: $20 for Tier 1 drugs; $60 for Tier 2 drugs; $120 for Tier 3 drugs. Specialty drugs are limited to a 30-day supply.
• 30-day retail and mail order specialty drugs: 20% coinsurance up to a maximum of $100 for Tier 4 specialty preferred; 20% coinsurance up to a maximum of $200 for Tier 5 specialty nonpreferred. Certain select specialty drugs are limited to a 15-day supply for the first prescription, reducing your copayment by half. 

Note: If you get a brand-name drug when a generic equivalent is on the BCN Custom Drug List, you have to pay the difference in cost between the brand-name drug and the generic in addition to your copayment for the Tier 2 or Tier 4 drug — unless your provider receives prior approval to designate the brand-name drug.

• Hearing services
  BCN will cover, in full, up to two hearing aids in the TruHearing formulary every 36 months regardless of age. Members may choose any hearing aid available through the TruHearing formulary at no out-of-pocket cost. The copays will be $15 primary care/$25 per specialist.
• Chiropractic care
  You pay $25 per office visit. Requires plan approval and a referral from your primary care provider.

• In physician's office 
• Office medical consultations
• In a skilled nursing facility
• At home

$15 per primary care provider visit

$25 per specialist visit

• Second surgical opinion

• In an urgent care center

$15 per visit or 50% of the approved amount, whichever is less

• During a hospital stay

• Online care 

Nothing

Not covered:

• Reversal of voluntary surgical sterilization

All charges

Telemedicine services

$15 per primary care provider visit

$25 per specialist visit

Tests, such as:

• Blood tests
• Urinalysis
• Nonroutine pap test
• Pathology
• X-ray
• Nonroutine mammogram
• Ultrasound
• CT/CAT Scans
• MRI
• Electrocardiogram and EEG

Nothing if received during your office visit; otherwise the following office visits may apply:

$15 per primary care provider visit 

$25 per specialist visit 

Routine physical every year.

The following preventive services are covered at the time interval recommended at each of the links below.

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/ 
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Routine mammogram — covered

Adult immunizations as endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations.

Note: Any procedure, injection, diagnostic service, laboratory, or x-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Not covered:

• Physical exams and immunizations required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure. 

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations 
  
  Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible. 

Nothing 

Complete maternity (obstetrical) care, to include:

• Prenatal care and Postpartum care
• Screening for gestational diabetes
• Screening and counseling for prenatal and postpartum depression

Nothing for routine prenatal and routine postpartum care visits

Office visit cost sharing applies to non-routine prenatal and non-routine postpartum visits 

• Delivery
• Breastfeeding support, supplies and counseling for each birth
  (see Durable medical equipment)

Notes: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery.  We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay.  We will cover other care of an infant who requires nonroutine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for nonmaternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b). 

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

A range of voluntary family planning services, limited to:

• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms
• Voluntary sterilization (tubal ligation, vasectomy). See Surgical Procedures Page (Applies to printed brochure only).

Note: We cover oral contraceptives under the prescription drug benefit.

Not covered:

• Reversal of voluntary surgical sterilization

All charges

BCN’s medical criteria require that the enrollee meet its definition of infertility.

BCN defines infertility as the result of a disease (an interruption, cessation, or disorder of body functions, systems, or organs) involving the reproductive system, which prevents conception. The American Society for Reproductive Medicine defines infertility as a failure to achieve pregnancy after 12 months of more of unprotected intercourse or egg-sperm contact for individuals under age 35 and 6 months for individuals aged 35 and older or due to an impairment of an individual’s capacity to reproduce either as an individual or with a partner due to medical history and diagnostic testing.

Please refer to Page (Applies to printed brochure only) for Definitions of Terms.

Diagnosis, counseling, and treatment of infertility including oral and injectable drugs are covered for infertile members when preauthorized based on BCN’s medical criteria.  Treatment services include:

• Artificial insemination:
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Iatrogenic preservation
• Assisted reproductive technology (ART) services, include, but not limited to the following procedures:
  • In-vitro fertilization (IVF)
  • Gamete intrafallopian transfer (GIFT)
  • Transuterine fallopian transfer (TUFT)
  • Natural oocyte retrieval with intravaginal fertilization (NORIF)
  • Pronuclear state tubal transfer (PROST)
  • Tubal embryo transfer (TET)
  • Zygote intrafallopian transfer (ZIFT)
  • Embryo(s) and sperm cryopreservation
  • Embryo and blastocyst transfer
  • Procedures associated with intracytoplasmic sperm injection (ICSI) for male infertility

• Fertility drugs (See Section 5f)

Note: We cover Injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.  

Not covered:

Exclusions include, but are not limited to:

• All services related to gestational surrogacy for non-members
• Third party reproductive services (e.g., donor eggs, sperm or embryos, traditional or gestational surrogacy)
• Assisted reproductive technology for fertile individuals
• Experimental treatment
• Reversal of prior sterilization

All charges

• Testing and treatment
• Allergy injections

$15 per primary care provider visit
$25 per specialist visit

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

• Chemotherapy and radiation therapy

Note: High-dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue
Transplants on Page (Applies to printed brochure only).

• Respiratory and inhalation therapy
• Cardiac rehabilitation following a qualifying event/condition is provided for up to 60 consecutive days
• Dialysis - hemodialysis and peritoneal dialysis
• Intravenous (IV) /infusion therapy - home IV and antibiotic therapy
• Applied Behavior Analysis (ABA) - coverage for these services to members of any age if they are medically necessary

Note: For applied behavior analysis, limitations and exclusions apply. Please contact BCN for additional information.

• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit and subject to the prescription copayment. We only cover GHT when we preauthorize the treatment.  We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on Page 19.

Nothing in outpatient facility setting

• 60 visits combined per medical diagnosis for physical therapy, medical rehabilitation and occupational therapy

Note: We only cover therapy when a physician:

− orders the care

− identifies the specific professional skills the patient requires and the medical necessity for skilled services; and

− indicates the length of time the services are needed.

$25 per visit or 50% of the approved amount, whichever is less 

Not covered:

• Long-term rehabilitative therapy
• Exercise programs
• Phases three and four of cardiac rehab

• For treatment related to illness or injury, including evaluation and
  diagnostic hearing tests performed by an M.D., D.O., or audiologist

$15 per primary care provider visit
$25 per specialist visit

• External hearing aids
  • Up to two hearing aids in the TruHearing formulary will be covered in full every 36 months regardless of age. Members may choose any hearing aid available through the TruHearing formulary at no out-of-pocket cost.
  • Inclusions with hearing aid purchase:
    • Risk-free 60-day trial period
    • Full 3-year manufacturer warranty (manufacturer and provider fees apply)
    • 1 year of follow-up visits
    • 80 free batteries per non-rechargeable hearing aid

Note: TruHearing is the delegated provider network for your hearing benefits. Members must schedule appointments through TruHearing at 1-833-414-6908 and see a TruHearing provider to use this benefit.

• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

For implanted devices benefits, see Section 5(b) Surgical and anesthesia services.

$15 per primary care provider visit

$25 per specialist visit

• Annual eye examination from Plan optometrists or ophthalmologists to determine the need for lenses to correct or improve eyesight. 

Note: Your vision benefits are administered by Vision Service Plan. Please contact Vision Service Plan at 800-877-7195 with questions about your vision benefits.

$5 per vision exam 

Non-Plan providers of vision services are paid at 75% of reasonable charges

• One pair of colorless plastic or glass lenses every 12 months when prescribed or dispensed by a physician or optician. The lenses may be single, bifocal, trifocal or lenticular.
• Elective contacts may be chosen instead of spectacle lenses and a frame. There is no copay for elective contacts, but you are responsible for any charges in excess of our allowance.
• We pay for one pair of medically necessary contact lenses every 12 months, in lieu of lenses and frames.

All charges above $150.00

• They are the only way to correct vision to 20/70 in the better eye; or
• They are the only effective treatment to correct keratoconus, irregular astigmatism or irregular corneal curvature.

All charges above $150.00

Not covered:

• Eye exercises
• Photo-sensitive lenses
• Nonmedically necessary tinted lenses
• Safety glasses
• Repair or replacement of lost or broken lenses or frames

• Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

$15 per primary care provider visit

$25 per specialist visit

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
• Corrective orthopedic appliances for nondental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome. 

Note: We cover basic items. Prior authorization is necessary for items with special features. See Section 3. You need plan approval for certain services.

50% of the approved amount

• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants and surgically implanted breast implant following mastectomy

Note: For information on the professional and facility charges for implanted devices, see Sections 5(b) and 5(c). The implanted device is part of the
surgical benefit and not subject to additional cost sharing. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads
  and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Repair or replacement due to loss or damage

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Motorized wheelchairs if medical criteria are met
• Crutches
• Walkers
• Audible prescription reading devices
• Speech generating devices
• Blood glucose monitors and testing supplies
• Insulin pumps
• Oxygen therapy
• Nebulizers and supplies 

Note: Call our DME provider, Northwood, at 800-667-8496 as soon as your Plan physician prescribes this equipment. Northwood specialists will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates. Contact Northwood for diabetic materials, including insulin pumps, blood glucose meters, test strips and lancets.

50% of the approved amount

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.) or home health aide.
• Services include oxygen therapy, intravenous therapy and medications.

$25 per visit or 50% of the approved amount, whichever is less 

Not covered:

• Nursing care requested by, or for the convenience of, the patient or  the patient’s family.
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic or rehabilitative.
• Custodial care in settings such as your home, a nursing home, residential institution or any other setting that is not required to support medical and skilled nursing care.

No benefits 

All charges 

• Chiropractic manipulation of the spine will be limited to 30 visits. 

See Section 3. You need plan approval for certain services.

• Chiropractic X-rays of the spine when taken by a chiropractor in the office

See Section 3. You need plan approval for certain services.

Nothing

• Tobacco cessation programs, including:
  • Individual/group counseling
  • 8 phone counseling sessions with trained counselors
  • 2 quit attempts per year
  • Approved nicotine replacement medications and supplies (see Prescription drug benefits)
• Multicomponent, family centered programs focused on childhood obesity that are part of intensive behavioral interventions (behavior change counseling for healthy diet and physical activity)

Note: We encourage you to look at our Blue Cross Health & Wellness suite of programs comprising health education, chronic condition and case management services that help you stay healthy, get better or improve your quality of life while living with an illness. 

The following are covered services when coverage criteria in Our Benefit, Referral and Practice Policy is met.

Must receive prior approval.

Supplemental feedings administered via tube:

This type of nutrition therapy is also known as enteral feeding. Formulas intended for this type of feeding as well as supplies, equipment, and accessories needed to administer this type of nutrition therapy, are covered.

Supplemental feedings administered via an IV:

This type of nutrition therapy is also known as parenteral nutrition. Nutrients, supplies, and equipment needed to administer this type of nutrition are covered.

Oral medical formula:

Metabolic formula for consumption by mouth for individuals of any age is considered covered when all of the following are met:

• The individual has a diagnosis of an inborn error of metabolism (IEM)* that requires oral medical formula; OR

The individual has an inherited condition that is proven to be treated by oral medical formula; AND,

• The oral medical formula is labeled and used for nutritional management of an inborn error of metabolism that interferes with the metabolism of specific nutrients (eg, Phenylketonuria, Homocystinuria, Maple Syrup Urine Disease, etc.); AND,
• The oral medical formula nutrition is ordered by a clinical or medical biochemical geneticist or by other qualified medical professionals in consultation with a clinical or medical biochemical geneticist

Covered:

Special food products and formulas that are part of a diet prescribed by a doctor for the treatment of phenylketonuria (PKU) or other inborn errors of metabolism. You can get most formulas used in the treatment of PKU or other inborn errors of metabolism from a drugstore.

Nothing

Not covered:

• Formula for any condition other than an inborn error of metabolism (eg, diabetes, hypercholesterolemia, etc.)
• Formula not specifically used for the nutrition of an individual with an inborn error of metabolism
• Medical food product that is not formula (eg, food modified to be low in protein [meat or cheese substitutes, pasta, etc.])
• Nutrition by tube feeding (refer to the Enteral Nutrition policy for guidelines)

All charges

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures 
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Voluntary sterilization (e.g., tubal ligation, vasectomy)
• Treatment of burns
• Surgical treatment of severe obesity (bariatric surgery)
  The criteria we consider are:
  - BMI
  - Age
  - Previous professional supervised weight loss programs
  - Patient's understanding of risks 
  - Presurgical psychological evaluation 

For more information, call 800-662-6667.

•  Insertion of internal prosthetic devices.  See 5(a) – Orthopedic and prosthetic devices for device coverage information

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done.  For example, we pay hospital benefits for a pacemaker and surgery benefits for insertion of the pacemaker.  See Hospital Benefits (Section 5c) and Surgery Benefits (Section 5b). 

Nothing 

Not covered: 

• Reversal of voluntary sterilization 
• Routine treatment of conditions of the foot (see Foot care)

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • The condition produced a major effect on the member’s appearance and
  • The condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities, cleft lip, cleft palate, birth marks, webbed fingers and webbed toes.
• Breast reconstructive surgery following a mastectomy for treatment of cancer, such as:
  • Surgery to produce a symmetrical appearance of breasts;
  • Treatment of any physical complications, such as lymphedemas;
  • Breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. See Hospital Benefits (Section 5c) and Surgery Benefits (Section 5b).

Gender Affirming Care and Services:

The safety and effectiveness of selected medical and surgical treatments for gender dysphoria are covered and include the following:

• Puberty suppression in adolescents
• Hormone therapy (for masculinization/feminization) for adolescents who meet criteria, and adults.
• Medically necessary gender affirming surgery*:
  • Genitalia reconstruction
  • Mastectomy for a transgender man (a person who has a gender identity as a man and who was assigned female at birth)
  • Augmentation mammoplasty (implants) for transgender women (a person who has a gender identity as a woman and who was assigned male at birth)
  • Thyroid reduction chondroplasty (tracheal shave)
  • Facial Feminization
  • Facial Masculinization

*Gender affirming surgery may require prior authorization.

$15 per primary care provider visit

$25 per specialist visit

Nothing in an inpatient or outpatient facility setting

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures; and
• Other surgical procedures that do not involve the teeth or their supporting structures.
• Treatment of temporomandibular joint (TMJ).

Note: If performed in a hospital setting, see Hospital Benefits (Section 5c) and Surgery Benefits (Section 5b).

These solid organ transplants are covered. Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Liver
• Lung: single/bilateral/lobar
• Pancreas
• Kidney-pancreas

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

Blood or marrow stem cell transplants Blue Care Network of Michigan extends coverage for the diagnoses as indicated below. 

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hematopoietic stem cell transplant
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Kostmann’s syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/myelodysplastic syndromes
  • Paroxysmal nocturnal hemoglobinuria
  • Phagocytic/hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing’s sarcoma
  • Hematopoietic stem cell transplant
  • Multiple myeloma
  • Medulloblastoma
  • Pineoblastoma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures:

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Acute myeloid leukemia
  • Advanced myeloproliferative disorders (MPDs)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, PNH, pure red cell aplasia)
  • Myelodysplasia/myelodysplastic syndromes
  • Paroxysmal nocturnal hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence and if approved by the Plan’s medical director in accordance with the Plan’s protocols. 

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition), if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Beta thalassemia major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or nonadvanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle cell anemia
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Chronic lymphocytic leukemia
  • Chronic myelogenous leukemia
  • Colon cancer
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myeloproliferative disorders (MSDs)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia
• Autologous Transplants for
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Aggressive non-Hodgkin lymphomas
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Chronic myelogenous leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or nonadvanced) small cell lymphocytic lymphoma
  • Mantle Cell (Non-Hodgkin's lymphoma)
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

National Transplant Program (NTP)

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

Nothing

Not covered:

• Donor screening tests and donor search expenses, except those shown above
• Implants of artificial organs
• Transplants not listed as covered

Professional services provided in –

• Hospital (inpatient)
• Hospital outpatient department
• Freestanding ambulatory surgical center
• Skilled nursing facility
• Office

Room and board, such as

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and x-rays
• Dressings, splints, casts and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home
• Administration of blood and blood products
• Blood or blood plasma, if not donated or replaced
• Dressings, splints, casts and sterile tray services

Note: We cover hospital services and supplies related to dental procedures when necessitated by a nondental physical impairment. We do not cover the dental procedures.

Not covered:

• Custodial care
• Personal comfort items, such as phone, television, barber services, guest meals and beds
• Private nursing care

• Operating, recovery and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Presurgical testing
• Dressings, casts and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service

• In the home
• In a skilled nursing facility

No benefits

All charges

• Nonemergency ground and air transport when preauthorized (See Section 5(d) for Emergency services/accidents.)

Not covered:

• Services provided by an emergency responder that do not include medical care or transportation are not covered.

• Emergency care at an urgent care center

• Emergency care in a hospital emergency room or as an outpatient at a hospital, including doctors' services

Note: We waive the ER copay if you are admitted as an inpatient to the hospital.

• Emergency ground and air transport when medically appropriate.

Note: See 5(c) for nonemergency service.

Not covered:

• Services provided by an emergency responder that do not include medical care or transportation are not covered.

We cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or family therapists.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management 
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services

Outpatient services provided and billed by a hospital or other covered facility

• Services in approved treatment programs, such as partial hospitalization, residential treatment, full-day hospitalization, or facility-based intensive outpatient treatment

We cover the following medications and supplies when prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as not covered
• Insulin
• Diabetic supplies limited to:
   Disposable needles and syringes for the administration of covered medications, lancets, select glucometers and testing strips.
• First time opiate prescriptions are limited to a five-day supply and members are responsible to pay the lesser of the contracted amount, Usual and Customary or copay for the generic or brand-name drug; whichever is less.

• 30- day retail and mail order
  • $10 for Tier 1 (generic drugs)
  • $30 for Tier 2 (preferred brand drugs)
  • $60 for Tier 3 (nonpreferred brand-name drugs) 
• 90-day retail and mail order
  • $20 for Tier 1 drugs 
  • $60 for Tier 2 drugs
  • $120 for Tier 3 drugs
• 30-day retail and mail order specialty drugs 
  • 20% coinsurance up to a maximum of $100 for Tier 4 (preferred specialty drugs)
  • 20% coinsurance up to a maximum of $200 for Tier 5 (nonpreferred specialty drugs)

Notes:

• Certain select specialty drugs are limited to a 15-day supply for the first prescription, reducing your copayment by half. 
• If there is no generic equivalent available and a brand-name drug is dispensed, you must pay the applicable brand copayment.
• Specialty drugs are covered only when obtained from AllianceRx Walgreens Pharmacy or Walgreens specialty or retail locations that are part of the BCN Exclusive Pharmacy Network for Specialty Drugs.

• Drugs to treat sexual dysfunction.
  • Contact Blue Care Network at 800-662-6667 for dose limits
• Drugs to treat gender dysphoria
  • Contact Blue Care Network at 800-662-6667 for dose limits

50% coinsurance up to the dose limit; all charges thereafter

Contraceptive drugs and devices as listed in the ACA/HRSA site.

Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below. 

• You can complete a Coverage Request Form online at bcbsm.com to request a review or exception to a prescription.
• Reimbursement for over-the-counter contraceptives can be submitted by calling Customer Service at 1-800-662-6667 or completing the Prescription drug reimbursement claim form at bcbsm.com.

• Tobacco and nicotine cessation drugs
• Other A and B rated preventive medications as recommended by the U.S. Preventive Services Task Force
  • Aspirin – men and women of certain ages
  • Folic Acid supplements – women who may become pregnant
  • Fluoride Chemoprevention supplements – children without fluoride in their water source

Note: Over-the-counter and prescription drugs require a written prescription by an approved provider.

Nothing for Tier 1 generics 

Drugs covered that comply with healthcare reform’s preventive benefits requirements under the ACA.

The following drugs and supplements are covered without cost-share, even if over-the-counter, are prescribed by a health care professional and filled at a network pharmacy.

• Aspirin (81 mg and 325mg) for men age 45-79 and women age 55-79 and women of childbearing age
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6
• Statin - Adults age 40-75 with no history of cardiovascular disease use low to moderate dose

Note:  To receive this benefit a prescription from a doctor must be presented to pharmacy.

Nothing for Tier 1 generic drugs

Not covered:

• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them.\
• Drugs and supplies for cosmetic purposes
• Replacement prescriptions resulting from loss, theft, or mishandling
• Marijuana (cannabis) for any use 
• Over the counter drugs except those listed above 
• Drugs and supplies for cosmetic purposes 
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Nonprescription medications medicines 

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco and nicotine dependence are covered under the tobacco and nicotine cessation program benefit. See page 36.

All charges

Members receive 8 over-the-counter COVID-19 test kits, per member, per 30 days

$10 generic tier copay

One of the many benefits of Blue Care Network of Michigan is coverage that travels with you. You can receive benefits when you’re away from home — on a short trip or for an extended time through BlueCard®. This Blue Cross and Blue Shield Association program gives members access to physicians in the United States wherever a Blue plan is offered. Call your primary care provider before you travel to arrange for coordinated care and required authorizations.

Learn more about the BlueCard program, which is part of your contract, by reading the disclosure document online at bcbsm.com/bluecarddisclosure or call Customer Service at 888-288-2738 to have a copy sent to you.

Any time, day or night, you have 24-hour phone access to coverage information. Our interactive voice response system provides answers to questions about coverage, eligibility and claims status. Of course, you can always reach us during our regular business hours (8 a.m. to 5:30 p.m. Monday through Friday).

Blue Care Network of Michigan members can score big savings on a variety of healthy products and services from businesses in Michigan and across the United States.

Member discounts with Blue365 offers exclusive deals on things like:

•  Fitness and wellness: Health magazines, fitness gear and gym memberships
• Healthy eating: Cookbooks, cooking classes and weight-loss programs
•  Lifestyle: Travel and recreation
• Personal care: Lasik and eye care services, dental care and hearing aids

Show your  Blue Care Network of Michigan ID card at participating local retailers or use an offer code online to take advantage of these savings. You can view all savings in one place through your member account at www.bcbsm.com.

Our website is a valuable resource for health information that can help you get the most from your coverage. Here’s some of what you can do:

• Complete a health assessment and develop a personal action plan.
• Verify eligibility for everyone on your contract.
• Order ID cards.
• View and print claim summaries.
• View your benefits.
• Change your primary care provider.
• Use our Coverage Advisor™ to compare health plans and their costs.

To access all these features, login to your account at www.bcbsm.com.

Health Education: 800-637-2972 

Blue Care Network of Michigan reminds members through various media (Good Health magazine; online health information; phone calls) to get important health screenings or services. The preventive recommendations include: screening tests for members with diabetes, breast cancer screenings, cervical cancer screenings, childhood and adolescent immunizations, flu vaccines and annual checkups.

Blue Care Network of Michigan members can also order self-help guides about nutritious eating, exercise, depression, high blood pressure, stress management, losing weight, back pain, cholesterol or quitting smoking.

You can get a picture of your health by taking the health assessment at bcbsm.com. To get started:

1. Log in to your member account at bcbsm.com.
2. Click on the Health and Well-Being tab, which will take you to the Blue Cross® Health and Well-Being website, powered by WebMD®.
   Please note: The first time you enter the Blue Cross Health and Well-Being site, you’ll need to register
3. Click on Take Your Health Assessment.

Note: WebMD Health Services is an independent company supporting Blue Care Network of Michigan by providing health and wellness services.

Your results will include:

• A health score based on an analysis of your health risks
• A list of your highest-risk areas
• A list of the next steps you can take to improve your health

The assessment takes about 10 minutes to complete. 

After you complete your health assessment on the Blue Cross Health and Well-Being site, you’ll receive recommendations for the Digital Health Assistant online coaching programs that are best for you. The Digital Health Assistant programs help you set small, achievable goals that you commit to for one week. You can choose activities, create a plan and track your progress right on the Blue Cross Health and Well-Being site.

When you use Blue Cross Online Visits^SM you'll have access to online medical and behavioral health services anywhere in the U.S. 

You can your covered family members can see and talk to a doctor for minor illnesses such as cold, flu or sore throat when their primary care doctor isn't available, or a behavioral health clinician or psychiatrist to help work through different challenges such as anxiety, depression and grief. 

After Jan. 1, 2018 to use online visits download the BCBSM Online Visits^SM app, visit bcbsmonlinevisits.com or call 844-606-1608.

Get answers to health care questions anytime, anywhere with support from registered nurses. Call 855-624-5214 to reach the 24-hour nurse advice line.

Blue Care Network of Michigan offers Medicare recipients the opportunity to enroll in this Plan through Medicare. Annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area. They may then later reenroll in the FEHB program. Most Federal annuitants have Medicare Part A. Those without Medicare Part A may join the Medicare prepaid Plan but will probably have to pay for hospital coverage in addition to the Part B premium. Before you join this Plan, ask whether this Plan covers hospital benefits and, if so, what you will have to pay. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan. Call us at 800-529-8360 for information on the Medicare prepaid Plan and the cost of that enrollment.

In most cases, providers and facilities file claims for you.  Providers must file on the form CMS-1500, Health Insurance Claim Form.  Your facility will file on the UB-04 form.  For claims questions and assistance, call us at 800-662-6667.

When you must file a claim – such as for services you received outside the Plan’s service area – submit it on the CMS-1500 or a claim form that includes the information shown below.  Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills. 

Submit your claims to: 

Member Claims
Blue Care Network of Michigan
P.O. Box 68767
Grand Rapids, MI 49516-8753

If a Member gets covered drugs, needles and syringes, or insulin from a nonparticipating pharmacy in an urgent situation or when out of area and a participating pharmacy is not available, Blue Care Network of Michigan will reimburse the amount specified on Blue Care Network of Michigan’s fee schedule or the actual charge, whichever is less, minus the copayment. Complete a Prescription Drug Reimbursement Form that is available online at www.bcbsm.com/billform or by calling Customer Service at 800-662-6667.

We will notify you of our decision within 30 days after we receive the claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review as long as we notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us.  For urgent care claims, we will permit a healthcare professional with knowledge of your medical condition to act as your authorized representative without your express consent.  For the purposes of this section, we are also referring to your authorized representative when we refer to you. 

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

Ask us in writing to reconsider our initial decision. You must:

a)   Write to us within six months from the date of our decision; and

b)   Send your request to us at:

Appeals and Grievances — Mail Code C248
Blue Care Network of Michigan
P.O. Box 284
Southfield, MI 48037-0284

c)    Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure.

d)    Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

e)    Include your email address (optional), if you would like to receive our decision via email.  Please note that by giving us your email, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date.  However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim, or  

b) Write to you and maintain our denial, or

c) Ask you or your provider for more information

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street, NW, Washington, DC 20415-3630. 

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note:  If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim appeals and the exchange of information by telephone, electronic mail, facsimile, or other methods.

Note:  You are the only person who has a right to file a disputed claim with OPM.  Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.  However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note:  The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct.  OPM will send you a final decision or notify you of the status of OPM’s review within 60 days.  There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue.  If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval.  This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision.  This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process.  Further, Federal law governs your lawsuit, benefits, and payment of benefits.  The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision.  You may recover only the amount of benefits in dispute.

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 800-662-6667. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal.  You may call OPM’s Health Insurance 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues.  For example, we do not determine whether you or a family member is covered under this plan. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault.  This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For example: 

• If you are covered under our Plan as a dependent, any group health insurance you have from your employer will pay primary and we will pay secondary. 
• If you are an annuitant under our Plan and also are actively employed, any group health insurance you have from your employer will pay primary and we will pay secondary. 
• When you are entitled to the payment of health care expenses under automobile insurance, including no-fault insurance and other insurance that pays without regard to fault, your automobile insurance is the primary payor and we are the secondary payor.

For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.bcbsm.com/fep

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan processes the benefit, we will pay what is left of our allowance, up to our regular benefit.  We will not pay more than our allowance.

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

Every job-related injury or illness should be reported as soon as possible to your supervisor. Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices. If you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment. If your medical treatment is accepted by the Dept. of Labor Office of Workers’ Compensation (OWCP), the provider will be compensated by OWCP. If your treatment is determined not job-related, we will process your benefit according to the terms of this plan, including use of in-network providers. Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it to your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this plan or by OWCP.

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage.

If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party’s insurance policies, your own insurance policies, or a workers’ compensation program or policy, you must reimburse us out of that payment. Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness. However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned. Our right of reimbursement is not subject to reduction based on attorney fees or costs under the "common fund" doctrine and is fully enforceable regardless of whether you are "made whole" or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on BENEFEDS.com, or by phone 877-888-3337, TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, Blue Care Network of Michigan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy.  These costs are covered by Blue Care Network of Michigan.
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. Blue Care Network of Michigan covers some of these costs, providing we determine the services are medically necessary.  Please contact Blue Care Network of Michigan to discuss specific services if you participate in a clinical trial.
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes.  These costs are generally covered by the clinical trials. Blue Care Network of Michigan does not cover these costs.

For more detailed information on “When you have Medicare” and “Should I Enroll in Medicare?” please contact Medicare at 1- 800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary.  This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-662-6667 or visit our website at www.bcbsm.com.

We do not waive any costs if the Original Medicare Plan is your primary payor.

Please review the following examples which illustrates your cost share if you are enrolled in Medicare Part B. If you purchase Medicare Part B, your provider is in our network and participates in Medicare, then we waive some costs because Medicare will be the primary payor. 

Benefit Description: Deductible
High Option You Pay Without Medicare: N/A
High Option You Pay With Medicare Part B: N/A

Benefit Description: Out-of-Pocket-Maximum
High Option You Pay Without Medicare: $6,350 self only/$12,700 family
High Option You Pay With Medicare Part B: $6,350 self only/$12,700 family

Benefit Description: Part B Premium Reimbursement Offered
High Option You Pay Without Medicare: N/A
High Option You Pay With Medicare Part B: N/A

Benefit Description: Primary Care Provider
High Option You Pay Without Medicare: $15 office copay
High Option You Pay With Medicare Part B: $15 office copay 

Benefit Description: Specialist
High Option You Pay Without Medicare: $25 office copay
High Option You Pay With Medicare Part B: $25 office copay 

Benefit Description: Inpatient Hospital
High Option You Pay Without Medicare: Nothing
High Option You Pay With Medicare Part B: Nothing 

Benefit Description: Outpatient Hospital
High Option You Pay Without Medicare: Nothing
High Option You Pay With Medicare Part B: Nothing 

Benefit Description: Prescription drugs: Retail and Mail order (90-day supply) Note: Specialty drugs are limited to a 30-day supply
High Option You Pay Without Medicare: 2x retail copay
High Option You Pay With Medicare Part B: 2x retail copay

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE (1-800-633-4227), TTY 800-486-2048 or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). However, we will not waive any of our copayments and coinsurance. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.
 

If you are enrolled in Medicare, and are not enrolled in a Medicare Advantage Plan (Part C), you have the opportunity to enroll in the Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP). The PDP EGWP is a prescription drug benefit for FEHB covered annuitants and their FEHB covered family members who are eligible for Medicare. This allows you to receive benefits that will never be less than your coverage that is available to members with only FEHB but more often you will receive benefits that are better than members with only FEHB. 

This Plan and our PDP EGWP: If you choose to enroll in our PDP EGWP, you will also continue to remain enrolled in our FEHB Plan. Participation in the PDP EGWP is voluntary, and you have the choice to opt out of this enrollment at any time.

In the case of those with higher incomes you may have a separate premium payment for your PDP EGWP benefit. Please refer to the Part D-IRMAA section of the Medicare website: https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug-plans to see if you would be subject to an additional premium. 

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.

·    We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignment shall be void. 

·    Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent care claim, for a representative to act on your behalf without designation) does not constitute an Assignment.

·    OPM’s contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity.  Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.

Refers to medical procedures other than artificial insemination used primarily to address infertility with the aim of achieving pregnancy. ART procedures specifically involve surgically removing eggs from an individual’s ovaries, combining them with sperm in the laboratory, and returning them to the individual’s body.

Blue Cross Health and Well-Being is a suite of programs comprising health education, chronic condition management, case management that help members stay healthy, get better or improve their quality of life while living with an illness. This umbrella of care provides members with the information and tools they need to make informed health care choices.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.

See Section 4, Page (Applies to printed brochure only)

See Section 4, Page (Applies to printed brochure only)

See Section 4, Page (Applies to printed brochure only)

See Section 4, Page (Applies to printed brochure only)

A product or procedure is considered not experimental or investigational if it meets all of the following conditions:

• It has final approval from the appropriate government regulatory bodies;
• The scientific evidence permits conclusions concerning the effect of the technology on health outcomes;
• The technology improves the net health outcome; and
• The technology is as beneficial as any established alternatives.

The investigational setting may be eliminated if the research and experimental stage of development is completed and the improvement in net health outcome is attainable outside the investigational settings.

Plan providers will follow generally accepted medical practice in prescribing any course of treatment. Before you enroll in this Plan, you should determine whether you would be able to accept treatment or procedures that may be recommended by this Plan’s providers.

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

BCN defines infertility as the result of a disease (an interruption, cessation, or disorder of body functions, systems, or organs) involving the reproductive system, which prevents conception. The American Society for Reproductive Medicine defines infertility as a failure to achieve pregnancy after 12 months of more of unprotected intercourse or egg-sperm contact for individuals under age 35 and 6 months for individuals aged 35 and older or due to an impairment of an individual’s capacity to reproduce either as an individual or with a partner due to medical history and diagnostic testing.

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways.

You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

A carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

An unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for

air ambulance services furnished by nonparticipating providers of air ambulance services.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims.  We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 800-662-6667.You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us and We refer to Blue Care Network of Michigan.

$15 copay per primary care provider visit
$25 copay per specialist visit

28

$25

35

Nothing

44

$100 copay

46

Regular cost-sharing 

48

$10 for Tier 1 (mostly generic)
$30 for Tier 2 (preferred brand-name)
$60 for Tier 3( nonpreferred brand-name)

51

$20 for Tier 1 (mostly generic)
$60 for Tier 2 (preferred brand-name)
$120 for Tier 3 (nonpreferred brand-name)
Speciality drugs are limited to a 30-day supply. 

51

• 20% coinsurance up to a maximum of $100 for Tier 4 specialty preferred 
• 20% coinsurance up to a maximum of $200 for Tier 5 specialty nonpreferred

Note: Certain select speciality drugs are limited to a 15-day supply for the first prescription, reducing your copayment by half. 

51

$25 copay

54

$5 copay per eye exam
$7.50 copay
All charges above $150.00

33

Out-of-pocket copayment maximum of $6,350 for Self Only, $12,700 for Self Plus One or $12,700 per Self and Family includes medical and prescription copayments and coinsurance

23

• Up to two hearing aids in the TruHearing formulary will be covered in full every 36 months regardless of age. Members may choose any hearing aid available through the TruHearing formulary at no out-of-pocket cost.
• $15 per primary care provider visit
• $25 per specialist visit

(Applies to printed brochure only)