with a preferred provider organization and a point-of-service product
Sponsored and administered by: The Blue Cross and Blue Shield
Association and participating local Blue Cross and Blue Shield Plans
Who
may enroll in this Plan: All Federal employees and annuitants who are
eligible to enroll in the FEHBP
Enrollment codes for this Plan:
101 High Option -Self Only 102 High
Option -Self and Family
104 Standard Option -Self Only 105 Standard Option
-Self and Family
RI 71-005 1
1 Page
2 3
2001 Blue Cross and Blue Shield
Service Benefit Plan 2 Table of Contents
Table of Contents
Introduction.................................................................................................................................................................
4
Plain
Language............................................................................................................................................................
4
Section 1. Facts about this fee-for-service Plan
.........................................................................................................
5
Section 2. How we change for 2001
..........................................................................................................................
7
Section 3. How you receive
benefits..........................................................................................................................
9
Identification
cards....................................................................................................................................
9
Where you get covered care
......................................................................................................................
9
Covered professional providers
........................................................................................................
9
Covered facility
providers...............................................................................................................
10
What you must do to get covered care
....................................................................................................
11
How to get approval for.
.........................................................................................................................
12
Your hospital stay (precertification)
...............................................................................................
12
Other services
.................................................................................................................................
14
Section 4. Your costs for covered services
..............................................................................................................
15
Copayments
....................................................................................................................................
15
Deductible
.......................................................................................................................................
15
Coinsurance
....................................................................................................................................
16
Differences between our allowance and the bill
............................................................................. 16
Your out-of-pocket
maximum.................................................................................................................
17
When government facilities bill
us..........................................................................................................
18
If we overpay you
...................................................................................................................................
18
When you are age 65 or over and you do not have
Medicare................................................................. 19
When you have
Medicare........................................................................................................................
20
Section 5. Benefits
...................................................................................................................................................
21
Overview.................................................................................................................................................
21
(a) Medical services and supplies provided by physicians and other health
care professionals ............ 22
(b) Surgical and anesthesia services
provided by physicians and other health care professionals ........ 40
(c)
Services provided by a hospital or other facility, and ambulance services
...................................... 48
(d) Emergency services/
accidents..........................................................................................................
57
(e) Mental health and substance abuse
benefits.....................................................................................
59
(f) Prescription drug benefits
................................................................................................................
65
(g) Special features
................................................................................................................................
69
(h) Dental benefits
.................................................................................................................................
70
(i) Non-FEHB benefits available to Plan
members...............................................................................
75 2
2 Page 3 4
2001 Blue Cross and Blue Shield Service Benefit Plan
3 Table of Contents
Section 6. General exclusions -things we
don't cover
...........................................................................................
76
Section 7. Filing a claim for covered
services........................................................................................................
77
Section 8. The disputed claims
process..................................................................................................................
80
Section 9. Coordinating benefits with other
coverage............................................................................................
82
When you have other health
coverage...................................................................................................
82
The Original Medicare Plan
..................................................................................................................
83
Medicare managed care
plan.................................................................................................................
85
TRICARE/ Workers'
Compensation.....................................................................................................
85
Medicaid................................................................................................................................................
86
When other Government agencies are responsible for your care
.......................................................... 86
When others
are responsible for injuries
...............................................................................................
86
Section 10. Definitions of terms we use in this
brochure.........................................................................................
87
Section 11. FEHB
facts............................................................................................................................................
93
Coverage
information............................................................................................................................
93
No pre-existing condition limitation
..............................................................................................
93
Where you get information about enrolling in the FEHB Program
............................................... 93
Types of coverage
available for you and your
family.................................................................... 93
When benefits and premiums
start.................................................................................................
94
Your medical and claims records are confidential
......................................................................... 94
When you
retire..............................................................................................................................
94
When you lose benefits
.........................................................................................................................
94
When FEHB coverage ends
...........................................................................................................
94
Spouse equity
coverage..................................................................................................................
94
Temporary Continuation of Coverage (TCC)
................................................................................
95
Converting to individual coverage
.................................................................................................
95
Getting a Certificate of Group Health Plan Coverage
........................................................................... 95
Inspector General
Advisory...................................................................................................................
96
Department of Defense/ FEHB Program Demonstration
Project...............................................................................
97
INDEX......................................................................................................................................................................
99
Summary of Standard Option benefits
....................................................................................................................
102
Summary of High Option benefits
..........................................................................................................................
103
Rates............................................................................................................................................................
Back cover 3
3 Page
4 5
2001 Blue Cross and Blue Shield
Service Benefit Plan 4 Introduction/ Plain Language
Introduction
Blue Cross and Blue Shield Service Benefit Plan
1310 G Street, NW, Suite 900
Washington, DC 20005
This Plan is
underwritten by participating Blue Cross and Blue Shield Plans (Local Plans)
that administer this Plan on behalf of the Blue Cross and Blue Shield
Association (the Carrier).
This brochure describes the benefits of the Blue Cross and Blue Shield
Service Benefit Plan under our contract (CS 1039) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health
Benefits
(FEHB) law. This brochure is the official statement of benefits. No
oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2001, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2001, and are
summarized on pages 7 and 8. Rates are shown at the end of this brochure.
Plain Language
The President and Vice President are making the
Government's communication more responsive, accessible, and understandable to
the public by requiring agencies to use plain language. In response, a team of
health plan
representatives and OPM staff worked cooperatively to make this
brochure clearer. Except for necessary technical terms, we use common words.
"You" means the enrollee or family member; "we" means the
Blue Cross and Blue
Shield Service Benefit Plan or the local Blue Cross and
Blue Shield Plans that administer it.
The plain language team reorganized
the brochure and the way we describe our benefits. When you compare this Plan
with other FEHB plans, you will find that the brochures have the same format and
similar information to make
comparisons easier.
If you have comments or
suggestions about how to improve this brochure, let us know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure, or e-mail us at
fehbwebcomments@ opm. gov, or write to OPM at the
Insurance Planning and
Evaluation Division, P. O. Box 436, Washington, DC 20044-0436. 4
4 Page 5 6
2001 Blue Cross and Blue Shield Service Benefit Plan
5 Section 1
Section 1. Facts about this fee-for-service plan
This Plan is a fee-for-service (FFS) plan. You can choose your own
hospitals, physicians, and other professional health care providers.
We reimburse you or your provider for your covered services, usually based on
a percentage of the amount we allow. The type and extent of covered services,
and the amount we allow, may be different from other plans. Read brochures
carefully.
We have Preferred Provider Organizations (PPO):
Our fee-for-service plan offers services through a PPO. When you use our
PPO providers, you will receive covered services at a reduced cost. Your Local
Plan (or for retail pharmacies, PCS Health Systems, Inc.) is solely responsible
for the selection of PPO providers in your area. Contact your Local Plan for
the names of PPO providers and to verify their continued participation. You can
also go to our web page, which you can reach through the FEHB web site,
www.
opm. gov/ insure. Do not call OPM or your agency for our provider directory.
Contact your Local Plan to request a PPO directory.
PPO benefits apply only when you use a PPO provider. PPO networks may be more
extensive in some areas than in others. We cannot guarantee the availability of
every specialty in all areas. If no PPO provider is available, or you do
not
use a PPO provider, the standard non-PPO benefits apply.
We also have
Point-of-Service (POS) benefits:
In certain areas, our fee-for-service
plan offers POS benefits to members who select Standard Option. This means you
can get better benefits at less out-of-pocket costs by signing up with us for
the POS program, selecting a contracted
POS primary care physician (PCP),
and letting the PCP manage your care. In Minnesota and North Dakota, you select
a primary care clinic rather than a primary care physician. If you go to another
provider without a referral from your
PCP, we will provide only regular
Standard Option non-PPO benefits. We offer the POS program in the following
areas: Connecticut, Georgia, Kansas, Louisiana (New Orleans area),
Massachusetts, Minnesota, New Jersey, New
York (areas served by the Empire
Plan), North Dakota (Fargo area), and Oklahoma. You can obtain a brochure
addendum from your Local Plan in these areas that describes our POS service
areas, benefit levels, and special
requirements.
How we pay
professional and facility providers:
We pay benefits when we receive a
claim for covered services. Each Local Plan contracts with hospitals and other
health care facilities, physicians, and non-physician health care professional
providers in its service area, and is
responsible for processing and paying
claims for services you receive within that area. Most, but not all, of these
contracted providers are in our PPO network.
= PPO providers. PPO providers have agreed to accept a specific
negotiated amount as payment in full for services provided to you. We refer to
PPO facility and professional providers as "Preferred." They will
generally
bill the Local Plan directly, who will then pay them directly. You
do not file a claim. Your out-of-pocket costs are generally less when you
receive services from PPO providers, and are limited to your applicable
deductible,
and coinsurance or copayments, for covered services. We provide
benefits for some services (such as a routine physical exam) only when you use
PPO providers.
= Participating providers. Some Local Plans also contract with other
providers that are not in our PPO network. If they are professionals, we refer
to them as "Participating" providers, and if they are facilities, we
refer to them
as "Member" facilities. They have agreed to accept a
different negotiated amount than our PPO providers as payment in full. They will
also generally file your claims for you. They have agreed not to bill you for
more
than your applicable deductible, and coinsurance or copayments, for
covered services. We pay them directly, but at our non-PPO benefit levels. Your
out-of-pocket costs will be greater than if you use PPO providers.
Note: Not all areas have participating providers and/ or member
facilities. To verify the status of a provider, please contact the Local Plan
serving the area where the services are to be performed. 5
5 Page 6 7
2001 Blue Cross and Blue Shield Service Benefit Plan
6 Section 1
= Non-participating providers. Providers who
are not PPO or Participating providers do not have contracts with us, and may or
may not accept our allowance. We refer to them as "Non-participating
providers" generally,
although if they are facilities we may refer to
them as "Non-member facilities." When you use Non-participating
providers, you may have to file your claim with us. We will then pay our
benefits to you, and you must pay the
provider.
You must pay any
difference between the amount Non-participating providers charge and our
allowance, in addition to any applicable coinsurance amounts, copayment amounts,
amounts applied to your calendar year
deductible, and amounts for noncovered
services. Important: Your out-of-pocket costs may be substantially higher
when you use Non-participating providers than when you use PPO or Participating
providers.
Note: In Local Plan areas other than those described below, PPO and
Participating providers who contract with us will generally accept 100% of the
Plan allowance as payment in full for covered services. As a result, you are
only
responsible for applicable coinsurance amounts, copayment amounts,
amounts applied to the calendar year deductible, and any charges for noncovered
services. However, this may not apply when there is another source of payment
besides you and us. When you have other coverage (see Section 9), the
following exceptions exist in our arrangements with PPO and Participating
professional providers. Contact your Local Plan if you have questions
about
the amounts PPO and Participating providers may collect from you.
= In
Arizona, when there is any other source of payment (whether we pay primary or
secondary), PPO and Participating physicians are not obligated to accept our
allowance as payment in full.
= In New York areas served by the Rochester Plan and in West Virginia, except
when we pay secondary to other Blue Cross and Blue Shield coverage administered
by the same Local Plan, PPO and Participating
physicians may collect the
difference between the total payments made by us and the primary carrier and the
physician's charge.
= In Pennsylvania and Utah, when we pay secondary, PPO physicians are not
obligated to accept our allowance as payment in full unless we make a payment as
the secondary payer.
= In Puerto Rico, when we pay secondary, PPO physicians
may collect the difference between the total payments made by us and the primary
carrier and the physician's charge.
= In Montana, when we pay secondary, PPO
and Participating physicians may collect the difference between the total
payments made by us and the primary carrier and the physician's charge.
= In
Rhode Island, South Carolina, and Vermont, except when we pay secondary to other
Blue Cross and Blue Shield coverage, PPO and Participating physicians may
collect the difference between the total
payments made by us and the primary
carrier and the physician's charge.
Patients' Bill of Rights
OPM requires that all FEHB Plans comply
with the Patients' Bill of Rights, recommended by the President's Advisory
Commission on Consumer Protection and Quality in the Health Care Industry. You
may get information
about us, our networks, and providers. You can also find
out about care management, including medical practice guidelines, disease
management programs, and how we determine if procedures are experimental or
investigational.
OPM's website (www. opm. gov/ insure) lists the specific
types of information that we must make available to you.
If you want more
information about us, call or write to us. Our telephone number and address are
shown on the back of your Service Benefit Plan ID card. You may also visit our
website at www. fepblue. org. 6
6 Page 7 8
2001 Blue Cross and
Blue Shield Service Benefit Plan 7 Section 2
Section 2. How we
change for 2001
Program-wide changes
= The plain language team
reorganized the brochure and the way we describe our benefits. We hope this will
make it easier for you to compare FEHB Plans.
= This year, the Federal Employees Health Benefits Program is implementing
network mental health and substance abuse parity. This means that your coverage
for network mental health, substance abuse, medical, surgical, and
hospital
services from providers in our PPO network will be the same with regard to
deductibles, coinsurance, copayments, and day and visit limitations when you
follow a treatment plan that we approve. Previously, we
placed higher
patient cost sharing or shorter day or visit limitations on mental health and
substance abuse services than we did on services to treat physical illness,
injury, or disease.
= Many health care organizations have turned their attention this past year
to improving health care quality and patient safety. OPM asked all FEHB Plans to
join them in this effort. You can find specific information on our
patient
safety activities by calling the telephone number on the back of your Plan ID
card, or checking our website www. fepblue. org. You can find out more
about patient safety on the OPM website,
www. opm. gov/ insure. To improve
your health care, take these five steps:
Speak up if you have questions or
concerns.
Keep a list of all the medicines you take.
Make sure you get
the results of any test or procedure.
Talk with your doctor and health care
team about your options if you need hospital care.
Make sure you understand
what will happen if you need surgery.
= We clarified the brochure language
to show that anyone who needs a mastectomy may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours after
the procedure.
Previously, the language referenced only women.
= North Dakota is deleted
from the list of states designated as medically underserved in 2001. See page 10
for information on medically underserved areas.
Changes to this Plan
= Your share of the non-Postal Standard
Option premium will increase by 14. 0% for Self Only or 21. 2% for Self and
Family.
= Your share of the non-Postal High Option premium will increase by 5. 8% for
Self Only or 3. 7% for Self and Family.
= We have enhanced our Mental Health
and Substance Abuse benefits. See Section 5( e).
= Your share for outpatient
facility services is now based on coinsurance:
Under Standard Option, you
now pay 10% of the Plan allowance at PPO facilities, and 25% of the Plan
allowance at Member and Non-member facilities. You also pay any difference
between the Plan allowance
and a Non-member facility's actual charge. Previously, your cost share was
$25 per day at PPO facilities, $100 per day at Member facilities, and $150 per
day at Non-member facilities. See Section 5( c).
Under High Option, you now pay 5% of the Plan allowance at PPO facilities,
and 20% of the Plan allowance at Member and Non-member facilities. You also pay
any difference between the Plan allowance and a Non-member
facility's actual
charge. Previously, your cost share was $10 per day at PPO facilities, $50 per
day at Member facilities, and $100 per day at Non-member facilities. See Section
5( c). 7
7 Page 8 9
2001 Blue Cross and Blue Shield Service Benefit Plan
8 Section 2
= Under Standard Option, your calendar year
deductible is now $250 per person/$ 500 per family. Previously, your calendar
year deductible was $200 per person/$ 400 per family. See Section 4.
= Under
Standard Option, your copayment for PPO home and office visits is now $15.
Previously, your copayment was $12. See Sections 5( a), 5( c) and 5( e).
=
Under Standard Option, your hospital inpatient per admission copayment is now
$100 per admission at PPO hospitals and $300 per admission at Member and
Non-member hospitals. Previously, you paid nothing per
admission at
Preferred hospitals and $250 per admission at Member and Non-member hospitals.
See Section 5( c).
= Under Standard Option, your catastrophic protection out-of-pocket limit is
now $3,000 per contract when you use only PPO providers and $5,000 per contract
when you use a combination of PPO and non-PPO providers.
Previously, your
out-of-pocket limit was $2000 (PPO only) and $3,750 (PPO and non-PPO). See
Section 4.
= Your cost sharing (deductibles, coinsurance or copayments) for
In-Network (Preferred) mental health and substance abuse services is now
included under the catastrophic protection out-of-pocket limit. See Section 4.
= You now pay $15 per visit under Standard Option and $12 per visit under
High Option for PPO office visits associated with hepatitis immunizations, and
nothing for the immunization. Previously, you paid (subject to
the
applicable calendar year deductible) 10% of the Plan allowance under Standard
Option and 5% of the Plan allowance under High Option. See Section 5( a).
= We now provide limited benefits under Standard and High Option for
audiologists, diabetic educators, dieticians, and nutritionists who bill
independently for covered services. See Section 3 and Section 5( a).
= We
now provide benefits under Standard and High Option for outpatient cardiac
rehabilitation when you obtain prior approval from your Local Plan. See Sections
5( a) and 5( c) for benefits, and Section 3 for prior approval
procedures.
= For your safety, we have placed additional limits on the quantities of
prescription drugs you may obtain through the Retail Pharmacy Program and the
Mail Service Prescription Drug Program, in accordance with
FDA guidelines.
= We have expanded our benefits for organ/ tissue
transplants to include all phagocytic deficiency diseases. See Section 5( b).
= We now provide benefits for inpatient stays in sub-acute units during a
medically necessary hospital admission. See Section 5( c).
= Our Standard
Option Point-of-Service (POS) program is no longer offered in the Cincinnati
area of Ohio.
= Under our Standard Option POS program, you now pay $15 per
visit for home, office, and clinic visits, nurse or home health aide visits, and
visits for physical, occupational, or speech therapy. Previously, you paid $10
per
visit. See your POS brochure addendum.
= Under our Standard Option POS
program, you now pay $50 per hospital emergency room visit and $40 per urgent
care center visit. Previously, you paid $35 (ER) and $25 (urgent care) per
visit. See your POS brochure
addendum.
= Under our Standard Option POS program, you now pay the lesser
of the actual charge, or $10 per generic prescription or $20 per brand name
prescription, for drugs obtained from a POS retail pharmacy. Previously,
your copayments were $5 (generic) and $15 (brand name). See your POS brochure
addendum. 8
8 Page 9
10
2001 Blue Cross and Blue Shield Service Benefit
Plan 9 Section 3
Section 3. How you receive benefits
Identification cards 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 covered provider, or fill a
prescription at a pharmacy participating in our Retail Pharmacy Program.
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 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 the Local Plan
serving the area where you reside and ask them to assist you, or write to us
directly at: FEP Enrollment Services, 550 12 th Street, SW,
Washington, DC
20065-1463.
Where you get covered care You can get care from any "covered
professional provider" or "covered facility provider." How much
we pay – and you pay – depends on the
type of covered provider
you use. If you use our PPO, Participating, or Member providers, or our
point-of-service program, you will pay less.
Covered professional providers We consider the following to be covered
professionals when they perform services within the scope of their license or
certification:
Physician -Doctors of medicine (M. D.); osteopathy (D.
O.); dental surgery (D. D. S.); medical dentistry (D. M. D.); podiatric medicine
(D. P. M.); and optometry (O. D.). Independent Laboratory -A
laboratory that is licensed under State
law or, where no licensing
requirement exists, that is approved by the Local Plan.
Qualified
Clinical Psychologist -A psychologist who (1) is licensed or certified in
the state where the services are performed;
(2) has a doctoral degree in
psychology (or an allied degree if, in the individual state, the academic
licensing/ certification requirement for
clinical psychologist is met by an
allied degree) or is approved by the Local Plan; and (3) has met the clinical
psychological experience
requirements of the individual State Licensing
Board. Nurse Midwife -A person who is certified by the American College
of Nurse Midwives or, if the state requires it, is licensed or certified as
a nurse midwife.
Nurse Practitioner/ Clinical Specialist -A person
who (1) has an active R. N. license in the United States; (2) has a
baccalaureate or
higher degree in nursing; and (3) if the state requires it,
is licensed or certified as a nurse practitioner or clinical nurse specialist.
Clinical Social Worker -A social worker who (1) has a master's or
doctoral degree in social work; (2) has at least two years of clinical
social work practice; and (3) if the state requires it, is licensed,
certified, or registered as a social worker where the services are
performed. Physical, Speech, and Occupational Therapist -A
professional
who is licensed where the services are performed or meets the
requirements of the Local Plan to provide physical, speech, or
occupational
therapy services. 9
9 Page
10 11
2001 Blue Cross and Blue Shield
Service Benefit Plan 10 Section 3
Nursing School Administered
Clinic -A clinic that (1) is licensed or certified in the state where
services are performed; and (2)
provides ambulatory care in an outpatient
setting -primarily in rural or inner-city areas where there is a shortage of
physicians. Services
billed for by these clinics are considered outpatient
"office" services rather than facility charges.
Audiologist -A professional who, if the state requires it, is
licensed, certified, or registered as an audiologist where the services are
performed.
Dietician -A professional who, if the state requires
it, is licensed, certified, or registered as a dietician where the services are
performed.
Diabetic educator -A professional who, if the state
requires it, is licensed, certified, or registered as a diabetic educator where
the
services are performed.
Nutritionist -A professional who, if the
state requires it, is licensed, certified, or registered as a nutritionist where
the services are
performed.
Other professional providers specifically shown in the
benefits descriptions in Section 5.
Medically underserved areas. Note: In medically underserved
areas, we cover any licensed medical practitioner for any covered service
performed within the scope of that license in states OPM determines are
"medically underserved." For 2001, the states are: Alabama, Idaho,
Kentucky, Louisiana, Mississippi, Missouri, New Mexico, South Carolina,
South Dakota, Utah, and Wyoming.
Covered facility providers Covered facilities include:
Hospital
-An institution, or a distinct portion of an institution, that:
(1)
Primarily provides diagnostic and therapeutic facilities for surgical and
medical diagnoses, treatment, and care of injured and sick
persons provided
or supervised by a staff of licensed doctors of medicine (M. D.) or licensed
doctors of osteopathy (D. O.), for
compensation from its patients, on an
inpatient or outpatient basis; (2) Continuously provides 24-hour-a-day
professional registered nursing
(R. N.) services; and (3) Is not, other than
incidentally, an extended care facility; a nursing
home; a place for rest;
an institution for exceptional children, the aged, drug addicts, or alcoholics;
or a custodial or domiciliary
institution having as its primary purpose the
furnishing of food, shelter, training, or non-medical personal services.
Note: We consider college infirmaries to be Non-member hospitals. In
addition, we may, at our discretion, recognize any institution located
outside the 50 states and the District of Columbia as a Non-member hospital.
Freestanding Ambulatory Facility -A freestanding facility, such as an
ambulatory surgical center, freestanding surgi-center,
freestanding dialysis
center, or freestanding ambulatory medical facility, that: 10
10 Page 11 12
2001 Blue Cross and Blue Shield Service Benefit
Plan 11 Section 3
(1) Provides services in an outpatient setting;
(2) Contains permanent amenities and equipment primarily for the
purpose of
performing medical, surgical, and/ or renal dialysis procedures;
(3)
Provides treatment performed or supervised by doctors and/ or nurses, and may
include other ancillary professional services
performed at the facility; and
(4) Is not, other than incidentally, an office or clinic for the private
practice of a doctor or other professional.
Note: We may, at our
discretion, recognize any other similar facilities, such as birthing centers, as
freestanding ambulatory facilities.
Cancer Research Facility -A facility that is:
(1) A National
Cooperative Center Cancer Study Group institution that is funded by the National
Cancer Institute (NCI) and has been
approved by a Cooperative Group as a
bone marrow transplant center;
(2) An NCI-designated Cancer Center; or (3)
An institution that has an NCI-funded, peer-reviewed grant to study
allogeneic or autologous bone marrow transplants and blood stem cell
transplant support.
Other facilities specifically listed in the benefits descriptions in Section
5( c).
What you must do to It depends on the kind of care you want to
receive. You can go to any get covered care provider you want, but in
some circumstances, we must approve care in
advance.
Transitional care Specialty Care: If you have a chronic or disabling
condition and lose access to PPO benefits for your specialist's services because
we:
= terminate our contract with your specialist for other than cause; or
=
drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll
in another FEHB plan;
you may be able to continue to receive PPO benefits for your specialist's
services 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 PPO
benefits for your specialist's services based on the above
circumstances,
you can continue to receive PPO benefits for your specialist's services until
the end of your postpartum care, even if it is
beyond the 90 days.
Hospital care Hospital care: If you are in the hospital when your
enrollment in our Plan begins, call us immediately. If you have not yet received
your
Service Benefit Plan ID card, you can contact your Local Plan at the
telephone number listed in your local telephone directory. If you already
have your new Service Benefit Plan ID card, call us at the number on the
back of the card. If you are new to the FEHB Program, we will
reimburse you
for your covered expenses while in the hospital. 11
11
Page 12 13
2001
Blue Cross and Blue Shield Service Benefit Plan 12 Section 3
However, 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; or
= 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.
How to get approval for…
Your hospital stay Precertification is the process by which –
prior to your inpatient hospital admission – we evaluate the medical
necessity of your proposed stay and
the number of days required to treat
your condition. Unless we are misled by the information given to us, we will not
change our decision on
medical necessity.
In most cases, your physician
or hospital will take care of precertification. Because you are still
responsible for ensuring that we
are asked to precertify your care, you
should always ask your physician or hospital whether they have contacted us.
Warning: We will reduce our benefits for the inpatient hospital stay
by $500 if no one contacts us for precertification. If the stay is not medically
necessary, we will not pay any benefits.
How to precertify an admission: You, your representative, your doctor,
or your hospital must call us at the telephone number listed on the back of your
Service Benefit
Plan ID card any time prior to admission.
= 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, your doctor, or your hospital must telephone us within
two business days following
the day of the emergency admission, even if you
have been discharged from the hospital.
= Provide the following information:
Enrollee's name and Plan
identification number;
Patient's name, birth date, and phone number;
Reason for hospitalization, proposed treatment, or surgery;
Name and
phone number of admitting doctor;
Name of hospital or facility; and
Number of planned days of confinement.
= We will then tell the doctor
and/ or hospital the number of approved inpatient days and we will send written
confirmation of our decision
to you, your doctor, and the hospital. 12
12 Page 13 14
2001 Blue Cross and Blue Shield Service Benefit
Plan 13 Section 3
Maternity care You do not need to
precertify 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, then your physician or the hospital
must contact us for precertification of additional
days for your baby.
If your hospital stay If your hospital stay, including for maternity
care, needs to be needs to be extended: extended, your doctor or the
hospital must ask us to approve the additional
days.
What happens
when you When we precertified the admission but you remained in the do
not follow the hospital beyond the number of days we approved and
precertification rules did not get the additional days precertified,
then:
for the part of the admission that was medically necessary, we will
pay inpatient benefits, but
for the part of the admission that was not medically necessary, we will pay
only medical services and supplies otherwise payable on
an outpatient basis
and we will not pay inpatient benefits.
= If no one contacted us, we will
decide whether the hospital stay was medically necessary.
If we determine that the stay was medically necessary, we will pay the
inpatient charges, less the $500 penalty.
If we determine that it was not
medically necessary for you to be an inpatient, we will not pay inpatient
hospital benefits. We will
only pay for any covered medical supplies and
services that are otherwise payable on an outpatient basis.
= If we denied the precertification request, we will not pay inpatient
hospital benefits or inpatient physician care benefits. We will only
pay for
any covered medical supplies and services that are otherwise payable on an
outpatient basis.
Exceptions: You do not need precertification in these cases:
= You
are admitted to a hospital outside the United States.
= You have another
group health insurance policy that is the primary payer for the hospital stay.
= Your Medicare Part A is the primary payer for the hospital stay. Note:
If you exhaust your Medicare hospital benefits and do not want
to use
your Medicare lifetime reserve days, then we will become the primary payer and
you do need precertification. 13
13 Page 14 15
2001 Blue Cross
and Blue Shield Service Benefit Plan 14 Section 3
Other
services These services require prior approval:
= Home health care
(High Option) -Contact us at the number listed on the back of your ID card
before obtaining services. We will
request the medical evidence we need to
make our coverage determination and advise you which home health care agencies
have
agreements with us.
= Home hospice care -Contact us at the
number listed on the back of your ID card before obtaining services. We will
request the medical
evidence we need to make our coverage determination and
advise you which home hospice care agencies we have approved.
= Partial hospitalization or intensive outpatient treatment for mental
health/ substance abuse -Contact us at the number listed on
the back of
your ID card for mental health and substance abuse before obtaining services for
intensive outpatient treatment or partial
hospitalization. We will request
the medical evidence we need to make our coverage determination. We will also
consider the
necessary duration of either of these services.
= Organ/
tissue transplants -Contact us at the number listed on the back of your ID
card before obtaining services. We will request the
medical evidence we need
to make our coverage determination. We will consider whether the facility is
approved for the procedure and
whether you meet the facility's criteria.
= Clinical trials for certain organ/ tissue transplants -Contact our
Clinical Trials Information Unit at 1-800-225-2268 for information
or to
request prior approval before obtaining services. We will request the medical
evidence we need to make our coverage
determination. Use this number only
for prior approval of clinical trials for bone marrow and peripheral blood
stem cell transplant
support procedures for those conditions shown on page
46 as covered only in clinical trials.
= Cardiac rehabilitation -Contact us at the number listed on the back
of your ID card prior to starting treatment. We will request the
information
we need to make our coverage determination.
= Prescription drugs
-Contact our Retail Pharmacy Program at 1-800-624-5060 (TDD: 1-800-624-5077
for the hearing impaired) to
request prior approval, or to obtain an updated
list of prescription drugs that require prior approval. We will request the
information
we need to make our coverage determination. You must
periodically renew prior approval for certain drugs.
Note: Until we approve them, you must pay for these drugs in full when
you purchase them at any retail pharmacy, even at Preferred
pharmacies, and
submit the expense( s) to us on a claim form. Preferred pharmacies will not file
these claims for you. Our Mail
Service Prescription Drug Program also will
not fill your prescription until you have prior approval. Merck-Medco Rx
Services, the administrator of the Mail Service Prescription Drug Program,
will return your prescription to you along with a Prior
Approval Request
Form and a letter explaining the prior approval procedures. 14
14 Page 15 16
2001 Blue Cross and Blue Shield Service Benefit
Plan 15 Section 4
Section 4. Your costs for covered services
This is what you will pay out-of-pocket for your covered care:
Copayments A copayment is a fixed amount of money you pay to the
provider when you receive certain services.
Example: When you see your PPO physician you pay a copayment of $15 per
visit.
We also have a per admission copayment for inpatient hospital
stays (except under High Option in Preferred hospitals). This is a fixed
amount of covered hospital room and board expenses you must pay once during
each hospital admission before we pay benefits. The per
admission copayment
does not apply to Preferred maternity care and High Option Preferred hospitals.
Note: If the billed amount (or the Plan allowance that providers we
contract with have agreed to accept as payment in full) is less than your
copayment, you pay the lower amount.
Deductible A deductible is a
fixed amount of covered expenses you must incur for certain covered services and
supplies before we start paying benefits for
them. Copayments do not count
toward any deductible. When a covered service or supply is subject to a
deductible, only the Plan allowance for
the service or supply that you then
pay counts toward meeting your deductible.
We have a calendar year deductible. The calendar year deductible is
$250 per person under Standard Option and $150 per person
under High Option.
Under a family enrollment, the calendar year deductible for each family member
is satisfied and benefits are
payable for all family members when the
combined covered expenses of the family reach $500 under Standard Option and
$300
under High Option.
Note: If the billed amount (or the Plan
allowance that providers we contract with have agreed to accept as payment in
full) is less than the
remaining portion of your deductible, you pay the
lower amount.
Example: If the billed amount is $100, the provider has an
agreement with us to accept $80, and you have not paid any amount toward meeting
your Standard Option calendar year deductible, you must pay $80. We will
apply $80 to your deductible. We will begin paying benefits once
the
remaining portion of your Standard Option calendar year deductible ($ 170) has
been satisfied.
Note: If you change plans during Open Season and the effective date of
your new plan is after January 1 of the next year, you do not have to start
a new deductible under your old plan between January 1 and the effective
date of your new plan. If you change plans at another time during the
year,
you must begin a new deductible under your new plan.
And, if you change
options in this Plan during the year, we will credit the amount of covered
expenses already applied toward the calendar year
deductible of your old
option to the calendar year deductible of your new option. 15
15 Page 16 17
2001 Blue Cross and Blue Shield Service Benefit
Plan 16 Section 4
Coinsurance Coinsurance is the
percentage of the Plan allowance that you must pay for your care. Coinsurance
does not begin until you meet your
deductible.
Example: You pay 20% of
the Plan allowance under High Option, or 25% of the Plan allowance under
Standard Option, for ambulance
transport services.
Note: Your
coinsurance is based on the Plan allowance, or the billed amount, whichever is
less.
Note: If your provider routinely waives (does not require you
to pay) your deductible, coinsurance or copayments, the provider is misstating
the fee and may be violating the law. In this case, when we calculate our
share, we will reduce the provider's fee by the amount waived.
Example: If your physician ordinarily charges $100 for a service but
routinely waives your 25% Standard Option coinsurance, the actual
charge is
$75. We will pay $56.25 (75% of the actual charge of $75).
Differences
between Our "Plan allowance" is the amount we use to calculate our
payment for our allowance and covered services. Fee-for-service plans
arrive at their allowances in
the bill different ways, so their
allowances vary. For information about how we determine our Plan allowance, see
the definition of Plan allowance in
Section 10.
Often, the provider's
bill is more than a fee-for-service plan's allowance. Whether or not you have to
pay the difference between our allowance
and the bill will depend on the
provider you use.
= PPO providers agree to limit what they bill you.
Because of that,
when you use a PPO provider, your share of covered charges
consists only of your deductible and coinsurance or copayment. Here is an
example: You see a PPO physician who charges $150, but our allowance is $100.
If you have met your deductible, you are only
responsible for your
coinsurance. That is, under Standard Option, you pay just 10% of our $100
allowance ($ 10). Because of the
agreement, your PPO physician will not bill
you for the $50 difference between our allowance and his/ her bill. See page 6
for
exceptions.
= Participating providers also agree to limit
what they bill you.
Because of that, when you use a Participating provider,
your share of covered charges consists only of your deductible and coinsurance
or
copayment. Here is an example: You see a Participating physician who charges
$150, but the Plan allowance is $100. If you have met
your deductible, you
are only responsible for your coinsurance. That is, under Standard Option, you
pay just 25% of our $100 allowance
($ 25). Because of the agreement, your
Participating physician will not bill you for the $50 difference between our
allowance and his/ her
bill. See page 6 for exceptions. 16
16 Page 17 18
2001 Blue Cross and Blue Shield Service Benefit
Plan 17 Section 4
= Non-participating providers, on the
other hand, have no agreement to
limit what they will bill you. When you use
a Non-participating provider, you will pay your deductible and coinsurance
-plus any
difference between our allowance and the charges on the bill. For example,
you see a Non-participating physician who charges $150.
The Plan allowance
is again $100, and you have met your deductible. You are responsible for your
coinsurance, so you pay 25% of the $100
Plan allowance or $25. Plus, because
there is no agreement between the Non-participating physician and us, the
physician can bill you for
the $50 difference between our allowance and his/
her bill.
The following table illustrates this example of how much you have
to pay out-of-pocket for services from a PPO physician, a Participating
physician, and a Non-participating physician. The table uses our example of
a service for which the physician charges $150 and the Plan
allowance is
$100. The table shows the amount you pay if you have met your calendar year
deductible.
EXAMPLE PPO physician Participating physician Non-participating physician
Physician's charge $150 $150 $150 Our allowance We set it at: 100 We set
it at: 100 We set it at: 100
We pay 90% of our allowance: 90 75% of our
allowance: 75 75% of our allowance: 75 You owe:
Coinsurance 10% of our
allowance: 10 25% of our allowance: 25 25% of our allowance: 25 +Difference up
to
charge? No: 0 No: 0 Yes: 50 TOTAL YOU PAY $10 $25 $75
Note: Had you not met any of your deductible in the above examples,
only our allowance ($ 100), which you would pay in full, would count
toward
your deductible.
° Overseas providers. We pay overseas claims at
PPO benefit levels, using an Overseas Fee Schedule as our Plan allowance. Most
overseas
providers are under no obligation to accept our allowance, and you must pay
any difference between our payment and the provider's bill.
See Section 5(
g) for more information about our overseas benefits.
Note: Under
Standard Option, we pay scheduled amounts for routine dental services and you
pay any balance. See Section 5( h) for
information about your costs for routine dental services.
Your
out-of-pocket maximum If the total amount of out-of-pocket expenses in a
calendar year for you for deductibles, coinsurance and your covered
family members for deductibles, coinsurance, and
and copayments
copayments (other than those indicated on the following page) exceeds $5000
under Standard Option, or $2,700 under High Option, then you
and any covered
family members will not have to continue paying them for the remainder of the
calendar year.
PPO maximum: If the total amount of these out-of-pocket expenses in a
calendar year from using PPO providers for you and your covered family
members exceeds $3,000 under Standard Option, or $1,000 under High Option,
then you and any covered family members will not have to pay
them for the
remainder of the calendar year when you continue to use PPO providers. You will,
however, have to pay them when you use non-PPO
providers, until your
out-of-pocket expenses reach $5000 under Standard Option, or $2,700 under High
Option, as shown above. 17
17 Page 18 19
2001 Blue Cross
and Blue Shield Service Benefit Plan 18 Section 4
The
following expenses are not included under this feature. These expenses do
not count toward your out-of-pocket maximum, and you
must continue to pay
them even after your expenses exceed the limits described on page 17:
= The difference between the Plan allowance and the billed amount. See page
16;
= Expenses for services, drugs, and supplies in excess of our maximum
benefit limitations;
= Your 30% coinsurance for inpatient care in a
Non-member hospital;
= Your 25% (Standard Option) and 20% (High Option)
coinsurance for outpatient care by a Non-member facility;
= Your expenses for mental conditions and substance abuse care by a non-PPO
professional or facility provider;
= Your expenses for dental services in excess of our fee schedule payments
under Standard Option. See Section 5( h); and
= The $500 penalty for failing
to obtain precertification, and any other amounts you pay because we reduce
benefits for not complying with
our cost containment requirements.
Note: If you change to another plan during Open Season, we will
continue to provide benefits between January 1 and the effective date of
your new plan.
= If you had already paid the out-of-pocket maximum, we
will continue to provide benefits as described above until the effective date of
your
new plan.
= If you had not yet paid the out-of-pocket maximum, we
will apply any expenses you incur in January (before the effective date of your
new plan) to our prior year's out-of-pocket maximum. Once you reach the
maximum, you don't need to pay our deductibles,
copayments or coinsurance amounts (except as shown above) from that point
until the effective date of your new plan.
Note: Because benefit changes are effective January 1, we will apply
our next year's benefits to any expenses you incur in January.
Note:
If you change options in this Plan during the year, we will credit the
amounts already accumulated toward the PPO and non-PPO out-of-pocket
limits
of your old option to the out-of-pocket limits of your new option. If you change
from Self Only to Self and Family, or vice versa,
during the calendar year,
please contact your Local Plan about your out-of-pocket accumulations and how
they carry over.
When government facilities Facilities of the Department of Veterans
Affairs, the Department of bill us Defense, and the Indian Health Service
are entitled to seek
reimbursement from us for certain services and supplies
they provide to you or a family member. They may not seek more than their
governing
laws allow.
If we overpay you We will make diligent efforts to recover benefit
payments we made in error but in good faith. We may reduce subsequent benefit
payments to
offset overpayments.
Note: We will generally first
seek recovery from the provider if we paid the provider directly, or from the
person (covered family member,
guardian, custodial parent, etc.) to whom we
sent our payment. 18
18 Page
19 20
2001 Blue Cross and Blue Shield
Service Benefit Plan 19 Section 4
When you are age 65 or over
and you do not have Medicare
Under the FEHB law, we must limit our
payments for those benefits you would be entitled to if you had Medicare. And,
your physician and hospital must follow Medicare rules and cannot bill you for
more than they could bill you if
you had Medicare. The following chart has
more information about the limits.
If you…
= are age 65 or
over, and
= do not have Medicare Part A, Part B, or both; and
= have
this Plan as an annuitant, as a former spouse, or as a family member of
an annuitant or former spouse; and
= are not employed in a position that gives FEHB coverage. (Your employing
office can tell you if this applies.)
Then, for your inpatient hospital care,
= the law requires us to
base our payment on an amount -the "equivalent Medicare amount" -set
by Medicare's rules for what Medicare will pay and not on the actual charge;
= you are responsible for your applicable deductible and coinsurance or
copayments you owe under this Plan;
= you are not responsible for any charges greater than the equivalent
Medicare amount; we will show that amount on the explanation of benefits (EOB)
form that we send you; and
= the law prohibits a hospital from collecting
more than the equivalent Medicare amount.
And, for your physician care,
the law requires us to base our payment and your applicable coinsurance
on…
= an amount -set by Medicare and called the "Medicare
approved amount" or
= the actual charge if it is lower than the
Medicare approved amount.
If your physician… Then you are responsible for…
Participates with Medicare or accepts Medicare assignment for the claim and
is in our PPO network
your deductibles, coinsurance, and copayments
Participates with Medicare or accepts Medicare assignment and is not
in our
PPO network
your deductibles, coinsurance, and copayments,
and any balance up to the Medicare approved
amount
Does not participate
with Medicare, and is in our PPO network your deductibles, coinsurance, and
copayments, and any balance up to 115% of the Medicare
approved amount
Note: In many cases, your payment will be less
because of our PPO agreements. Contact your
Local Plan for information about what your specific PPO provider can collect
from you.
Does not participate with Medicare and is not in our PPO network your
deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare
approved amount
It is generally to your financial advantage to use a
physician who participates with Medicare. Such physicians are only permitted to
collect up to the Medicare approved amount.
Our explanation of benefits (EOB) form will tell you how much the physician
or hospital can collect from you. If your physician or hospital tries to collect
more than allowed by law, ask the physician or hospital to reduce the charges.
If
you have paid more than allowed, ask for a refund. If you need further
assistance, call us. 19
19 Page
20 21
2001 Blue Cross and Blue Shield
Service Benefit Plan 20 Section 4
When you have the We
limit our payment to an amount that supplements the benefits that Original
Medicare Plan Medicare would pay under Medicare Part A (Hospital Insurance)
and
Medicare Part B (Medical Insurance), regardless of whether Medicare
pays.
Note: We pay our regular benefits for emergency services to a facility
provider, such as a hospital, that does not participate with Medicare and
is
not reimbursed by Medicare.
If you are covered by Medicare Part B and it is
primary, your out-of-pocket costs for services that both we and Medicare cover
depend on
whether your physician accepts Medicare assignment for the claim.
= If your physician accepts Medicare assignment, then you pay nothing
for covered charges.
= If your physician does not accept Medicare assignment, then you pay
the
difference between our payment combined with Medicare's payment, and the charge.
Note: The physician who does not accept Medicare assignment may not
bill you for more than 115% of the amount Medicare bases its payment
on,
called the "limiting charge." The Medicare Summary Notice (MSN) form
that you receive from Medicare will have more information about
the limiting
charge. If your physician tries to collect more than allowed by law, ask them to
reduce their charges. If they do not, report them to
your Medicare carrier
who sent you the MSN form. Call us if you need further assistance.
When you have a Medicare A physician may ask you to sign a private
contract agreeing that you can Private Contract be billed directly for
services ordinarily covered by Medicare. Should
you sign an agreement,
Medicare will not pay any portion of the charges, and we will not increase our
payment to you or the physician. We will
still limit our payment to the
amount we would have paid after Medicare's payment. You will be responsible for
paying the difference
between the limiting charge and the amount we paid.
Please see Section 9, Coordinating benefits with other coverage, for
more information about how we coordinate benefits with Medicare. 20
20 Page 21 22
2001 Blue Cross and Blue Shield Service Benefit
Plan 21 Section 5
Section 5. Benefits -OVERVIEW
(See pages 7-8 for how our benefits changed this year and pages
102-103 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General exclusions in Section 6; they apply to
the
benefits in the following subsections. To obtain claim forms, claims filing
advice, or more information about our benefits, contact us at the telephone
number on the back of your Service Benefit Plan ID card or
at our website at
www. fepblue. org.
(a) Medical services and supplies provided by physicians and other health
care professionals...................... 22-39
= Diagnostic and treatment
services
= Lab, X-ray, and other diagnostic tests
= Preventive care,
adult
= Preventive care, children
= Maternity care
= Family planning
= Infertility services
= Allergy care
= Treatment therapies
=
Rehabilitative therapies
= Hearing services (testing, treatment, and
supplies)
= Vision services (testing, treatment, and
supplies) = Foot care
= Orthopedic and prosthetic devices
= Durable medical equipment (DME)
= Medical supplies
= Home health services
= Alternative treatments
= Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals .................. 40-47
= Surgical procedures
=
Reconstructive surgery
= Oral and maxillofacial surgery
= Organ/ tissue transplants
= Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services................................................ 48-56
= Inpatient
hospital
= Outpatient hospital or ambulatory surgical
center = Extended
care benefits/ Skilled nursing
care facility benefits
= Hospice care
= Ambulance
= Home health care
(d) Emergency services/ Accidents
..................................................................................................................
57-58
= Accidental injury
= Medical emergency
= Ambulance
(e) Mental health and substance abuse benefit
................................................................................................
59-64
(f) Prescription drug benefits
..........................................................................................................................
65-68
(g).. Special features
...............................................................................................................................................
69 Health support programs
= Flexible benefits option
= 24-hour nurse line
= Services for the deaf and hearing impaired
= Travel benefit/ services
overseas
(h) Dental benefits
...........................................................................................................................................
70-74
(i) Non-FEHB benefits available to Plan members
.............................................................................................
75
General exclusions
.................................................................................................................................................
76
SUMMARY OF
BENEFITS...........................................................................................................................
102-103 21
21 Page
22 23
2001 Blue Cross and Blue Shield
Service Benefit Plan 22 Section 5( a)
Section 5 (a). Medical
services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things you should keep in mind about these
benefits:
= Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
= The calendar year deductible is: $250 per person ($ 500 per family) under
Standard Option and $150 per person ($ 300 per family) under High
Option. The calendar year deductible
applies to almost all benefits in
this Section. We added "( No deductible)" to show when the calendar
year deductible does not apply.
= Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works, with special sections for
members who are age 65 or over. Also
read Section 9 about coordinating
benefits with other coverage, including Medicare.
= The non-PPO benefits are
the standard benefits of this Plan. PPO benefits apply only when you use a PPO
provider. When no PPO provider is available, non-PPO benefits apply.
= We base payment on whether a facility or a health care professional bills
for the services or supplies. You will find that some benefits are listed in
more than one section of the
brochure. This is because how they are paid
depends on what type of provider bills for the service. For example, physical
therapy is paid differently depending on whether it is billed
by an
inpatient facility, a doctor, a physical therapist, or an outpatient facility.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in
this Section. We say "No deductible" when it does not apply.
Diagnostic and treatment services You pay – Standard Option You pay
– High Option
Professional services of physicians:
=
Outpatient consultations
= Second surgical opinions
= Office visits
= Home visits
Preferred: $15 copayment for the office visit charge (No
deductible); 10%
of the Plan allowance for all other
services (deductible applies)
Participating: 25% of the Plan allowance
Non-participating: 25% of the
Plan allowance, plus any
difference between our allowance and the
physician's actual charge
Preferred: $12 copayment for the office visit charge
(No deductible); 5%
of the Plan allowance for all
other services (deductible applies)
Participating: 20% of the Plan allowance
Non-participating: 20% of the
Plan allowance, plus
any difference between our allowance and the
physician's actual charge
Diagnostic and treatment services – Continued on next page 22
22 Page 23 24
2001 Blue Cross and Blue Shield Service Benefit
Plan 23 Section 5( a)
Diagnostic and treatment services
-Continued You pay – Standard Option You pay – High Option
Professional services of physicians (cont'd):
= During a hospital
stay
= Services for nonsurgical procedures when ordered, provided, and
billed by a physician
during a covered inpatient hospital admission
= Medical care by the
attending physician (the physician who is primarily responsible for your
care when you are hospitalized) on days we pay Inpatient Hospital Benefits.
Note: A consulting
physician employed by the hospital is not the
attending physician
= Consultations when requested by the attending physician
= Concurrent
care – hospital inpatient care by a physician other than the attending
physician for
a condition not related to your primary diagnosis, or because
the medical complexity of
your condition requires this additional medical
care
= Physical therapy by a physician other than the attending physician
=
Initial examination of a newborn needing definitive treatment when covered under
a
family enrollment
= Pharmacotherapy (See Section 5( f) for coverage
for prescription drugs)
= Neurological testing
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan
allowance, plus any difference between
our
allowance and the physician's actual charge
Preferred: 5% of the Plan allowance (No
deductible)
Participating:
20% of the Plan
allowance (No deductible)
Non-participating: 20% of the Plan
allowance (No deductible), plus
any difference between our
allowance and the physician's actual
charge
Diagnostic and treatment services – Continued on next page 23
23 Page 24 25
2001 Blue Cross and Blue Shield Service Benefit
Plan 24 Section 5( a)
Diagnostic and treatment services
-Continued You pay – Standard Option You pay – High Option
Not covered:
= Routine services except for those
Preventive care services described on pages 26-28
= Inpatient private duty nursing
= Standby physicians
=
Routine radiological and staff consultations required by hospital rules and
regulations
= Inpatient physician care when your hospital admission or portion of an
admission is not
covered [( see Section 5( c)]
Note: If we determine
that a hospital admission is not covered, we will not provide benefits for
inpatient room and board or inpatient physician care. However, we will
provide benefits for
covered services or supplies other than room and board
and inhospital physician care at the level
that we would have paid if they
had been provided in some other setting.
All charges All charges 24
24 Page 25 26
2001 Blue Cross
and Blue Shield Service Benefit Plan 25 Section 5( a)
Lab,
X-ray and other diagnostic tests You pay – Standard Option You pay –
High Option
Diagnostic tests provided, or ordered and billed by a
physician, such as:
= Blood tests
= CT Scans/ MRIs
= EKGs and EEGs
= Laboratory tests
= Pathological services
= Ultrasounds
= Urinalysis
= X-rays
= Fecal occult blood tests*
= Non-routine mammograms*
= Non-routine
Pap tests*
= PSA tests*
= Sigmoidoscopies*
Laboratory and
pathological services billed by an independent laboratory
Note: If your PPO provider uses a non-PPO laboratory or radiologist,
we will pay non-PPO
benefits for any laboratory and X-ray charges.
Preferred: 10% of the Plan allowance; For
services marked with (*), $15
copayment for
associated office visits (No deductible);
nothing for
services or tests
Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance,
plus any difference between
our allowance
and the physician's actual charge
Preferred: 5% of the Plan allowance; For
services marked with (*), $12
copayment for
associated office visits (No deductible); nothing
for
services or tests
Participating: 20% of the Plan allowance
Non-participating: 20% of the Plan allowance,
plus any difference between
our allowance
and the physician's actual charge 25
25 Page 26 27
2001 Blue Cross and Blue Shield Service Benefit
Plan 26 Section 5( a)
Preventive care, adult You pay –
Standard Option You pay – High Option
Home and office visits for
routine (screening) physical examinations
= Under age 65 – once every three calendar years
= Age 65 and older
– once each calendar year
A routine physical examination may consist
of:
= History and risk assessment
= Chest X-ray
= EKG
=
Urinalysis
= Basic or comprehensive metabolic panel test
= CBC
= Cholesterol tests (may be done by any independent laboratory)
Note: These benefits do not apply to children. (See benefits under
Preventive care, children, this
section.)
Note: When billed by a
facility, such as the outpatient department of a hospital, we provide
benefits as shown here, according to the contracting status of the provider.
Note: We provide benefits for adult routine physical examinations only
when you receive
these services from a Preferred provider.
Preferred: $15 copayment for
associated office visits (No deductible);
nothing for services or tests
Participating: All charges
Non-participating: All charges
Preferred: $12 copayment for
associated office visits (No
deductible); nothing for services or tests
Participating: All charges
Non-participating: All charges
Preventive care, adult – Continued on next page 26
26 Page 27 28
2001 Blue Cross and Blue Shield Service Benefit
Plan 27 Section 5( a)
Preventive care, adult –
Continued You pay – Standard Option You pay – High
Option
Cancer screening
= Colorectal cancer screening, including:
Fecal occult blood test – one annually starting at age 40 *
Sigmoidoscopy – one every five years starting at age 50 *
=
Prostate cancer screening -Prostate Specific Antigen (PSA test) – one
annually for males
age 40 and older *
= Cervical cancer screening
– one routine Pap test annually for females of any age *
= Breast cancer screening – routine mammograms for females age 35 and
older,
as follows*
From age 35 through 39, one during this five-year
period
From age 40 through 64, one annually
At age 65 and older, one every two
consecutive calendar years
* Scheduled limits apply only to Participating and Non-participating
providers
Note: We provide benefits in full for preventive
(screening) tests and immunizations only when you
receive these services
from a Preferred physician on an outpatient basis. If these services are billed
separately from the routine physical examination, you may be responsible to
pay an additional
copayment for each office visit billed.
Note:
When billed by a facility, such as the outpatient department of a hospital,
we provide
benefits as shown here, according to the contracting status of the provider.
Preferred: $15 copayment for
associated office visits (No deductible);
nothing
for services or tests
Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance, plus
any difference between
our allowance and the
physician's actual charge
Preferred: $12 copayment for
associated office visits (No deductible);
nothing
for services or tests
Participating: 20% of the Plan allowance
Non-participating: 20% of the Plan allowance,
plus any difference between
our allowance
and the physician's actual charge
Preventive care, adult – Continued on next page. 27
27 Page 28 29
2001 Blue Cross and Blue Shield Service Benefit
Plan 28 Section 5( a)
Preventive care, adult -Continued You
pay – Standard Option You pay – High Option
Routine
immunizations without regard to age, limited to:
= Hepatitis immunizations for patients with increased risk or family history
= Influenza and pneumococcal vaccines, annually
= Lyme disease vaccine
= Tetanus-diphtheria (Td) booster – once every 10 years
Preferred: $15 copayment for
associated office visits (No deductible);
nothing for
services or tests
Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance, plus
any difference between
our allowance and the
physician's actual charge
Preferred: $12 copayment for
associated office visits (No deductible);
nothing
for services or tests
Participating: 20% of the Plan allowance
Non-participating: 20% of the Plan allowance,
plus any difference between
our allowance
and the physician's actual charge
Not covered: Office visit charges associated with preventive services and
routine
immunizations performed by Participating and Non-participating
providers.
All charges All charges
Preventive care, children You pay – Standard Option You pay –
High Option
We provide benefits for the following services:
= All
healthy newborn visits including routine screening (inpatient or outpatient)
= The following routine services as recommended by the American Academy of
Pediatrics for children up to the age of 22, including children living,
traveling, or adopted
from outside the United States:
Routine physical
examinations
Routine hearing tests
Laboratory tests
Immunizations
Related office visits
Note: When billed by a facility, such as
the outpatient department of a hospital, we provide
benefits as shown here, according to the contracting status of the provider.
Preferred: Nothing (No deductible)
Participating: Nothing (No deductible)
Non-participating: Nothing (No deductible) up to the
Plan allowance. You
are responsible only for any
difference between our allowance and the
physician's actual charge
Preferred: Nothing (No deductible)
Participating: Nothing (No deductible)
Non-participating: Nothing (No deductible)
up to the Plan allowance. You
are
responsible only for any difference between our
allowance and the
physician's actual
charge 28
28 Page 29 30
2001 Blue Cross
and Blue Shield Service Benefit Plan 29 Section 5( a)
Maternity care You pay – Standard Option You pay – High
Option
Complete maternity (obstetrical) care including related
conditions resulting in childbirth or
miscarriage when provided, or ordered and billed by a physician or nurse
midwife, such as:
= Prenatal care
= Delivery
= Postpartum care
Note: Here
are some things to keep in mind:
= You do not need to precertify your normal
delivery; see page 13 for other circumstances,
such as extended stays for you or your baby.
= You may remain in the
hospital up to 48 hours after a regular delivery and 96 hours after a
cesarean delivery. We will cover an extended stay, if medically necessary,
but you must
precertify the extended stay. See Section 3 for information on
requesting additional days.
= We cover routine nursery care of the newborn child during the covered
portion of the
mother's maternity stay, or if the child is covered under the
father's Self and Family
enrollment. We cover other care of a newborn who
requires definitive treatment as a patient,
such as circumcision, or
incubation for prematurity, only if we cover the newborn
under a Self and
Family enrollment.
= We pay assistant surgeon services (delivery) and
anesthesia the same as for illness or injury.
See Surgery benefits (Section 5b).
= For inpatient and outpatient
facility care related to maternity, we waive the per admission copay
and services are paid in full when you use Preferred providers.
Preferred: Nothing (No deductible)
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus
any difference between
our allowance and the
physician's actual charge
Preferred: Nothing (No deductible)
Participating: 20% of the Plan
allowance (No
deductible)
Non-participating: 20% of the Plan allowance
(No deductible), plus any difference between
our allowance and the
physician's actual
charge
Not covered:
Procedures, services, drugs and supplies related to
abortions except when the life of the mother would be
endangered if the fetus were carried to term or when the pregnancy is the
result of an act of rape or incest.
All charges All charges 29
29 Page 30 31
2001 Blue Cross
and Blue Shield Service Benefit Plan 30 Section 5( a)
Family
planning You pay – Standard Option You pay – High Option
We
provide benefits for:
= Depo-Provera
= Diaphragms
= Intrauterine
devices (IUDs)
= Norplant
= Oral contraceptives
= Voluntary
sterilization
Note: See Prescription Drugs, Section 5( f), for our
coverage for IUDs, Norplant, Depo-Provera,
diaphragms and oral contraceptives obtained from a retail pharmacy. Oral
contraceptives may
also be obtained through the Mail Service Prescription
Drug Program.
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus any
difference between
our allowance and the
physician's actual charge
Preferred: 5% of the Plan allowance (No deductible)
Participating: 20% of
the Plan allowance (No
deductible)
Non-participating: 20% of the Plan
allowance (No
deductible), plus any difference between our
allowance and
the physician's actual charge
Not covered:
= Reversal of voluntary sterilization
=
Contraceptive devices not described above
All charges All charges
Infertility services You pay – Standard Option You pay – High
Option
Diagnosis and treatment of infertility, except as excluded below
Note: See Section 5( f) for prescription drug coverage.
Preferred:
10% of the Plan allowance
Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance, plus any
difference between
our allowance and the
physician's actual charge
Preferred: 5% of the Plan allowance (No deductible)
Participating: 20% of
the Plan allowance (No
deductible)
Non-participating: 20% of the Plan
allowance (No
deductible), plus any difference between our
allowance and
the physician's actual charge
Not covered:
= Assisted reproductive technology (ART)
procedures, such as:
artificial insemination (AI)
in vitro fertilization (IVF)
embryo transfer and Gamete Intrafallopian Transfer (GIFT)
intravaginal insemination (IVI)
intra-cervical insemination
(ICI)
intrauterine insemination (IUI)
= Services and
supplies related to ART procedures, such as sperm banking
All charges All charges 30
30 Page 31 32
2001 Blue Cross
and Blue Shield Service Benefit Plan 31 Section 5( a)
Allergy
care You pay – Standard Option You pay – High Option
Testing
and treatment, including materials (such as allergy serum) and injections
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance, plus
any difference between
our allowance and the
physician's actual charge
Preferred: 5% of the Plan allowance
Participating: 20% of the Plan
allowance
Non-participating: 20% of the Plan allowance,
plus any difference between
our allowance
and the physician's actual charge
Not covered:
= Provocative food testing and sublingual allergy
desensitization
All charges All charges
Treatment therapies You pay – Standard Option You pay – High
Option
= Chemotherapy and radiation therapy
Note: We cover
high dose chemotherapy and/ or radiation therapy in connection with bone
marrow transplants, and drugs or medications to stimulate or mobilize stem
cells for transplant
procedures, only for those conditions listed as covered
under Organ/ tissue transplants in Section
5( b). See also, Services
requiring our prior approval, in Section 3.
= Renal dialysis – Hemodialysis and peritoneal dialysis
=
Intravenous (IV)/ Infusion therapy – Home IV therapy
Note: Home
nursing visits associated with Home IV therapy are covered as shown under Home
health services on page 37.
Outpatient cardiac rehabilitation. (Prior
approval is required. See Section 3.)
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus
any
difference between our allowance and the
physician's actual charge
Preferred: 5% of the Plan allowance
Participating: 20% of the Plan
allowance
Non-participating: 20% of the Plan allowance,
plus any
difference between our allowance
and the physician's actual charge 31
31 Page 32 33
2001 Blue Cross and Blue Shield Service Benefit
Plan 32 Section 5( a)
Rehabilitative therapies You pay –
Standard Option You pay – High Option
Physical therapy,
occupational therapy, and speech therapy – when performed by a physical
therapist, occupational therapist, speech therapist or physician
Physical therapy:
= Up to 50 visits for physical therapy per person, per
calendar year under Standard
Option
= Up to 75 visits for physical therapy per person, per
calendar year under High Option
Acupuncture as a physical therapy modality and for pain management if
performed by a physician
or licensed physical therapist
Occupational and
Speech therapy:
= Up to 25 visits for occupational therapy, speech therapy,
or a combination of both, per
person, per calendar year under both Standard Option and High
Option
Note: Visits that you pay for while meeting your calendar year
deductible count toward the limits
cited above.
When billed by a skilled
nursing facility, nursing home, or extended care facility, we pay benefits
as shown here for professional care, according to the contracting status of
the therapist.
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus
any
difference between our allowance and the
provider's actual charge
Preferred: 5% of the Plan allowance
Participating: 20% of the Plan
allowance
Non-participating: 20% of the Plan allowance,
plus any
difference between our allowance
and the provider's actual charge
Not covered:
= Maintenance or palliative rehabilitative therapy
= Exercise programs
= Hippotherapy
=
Recreational or educational therapy, and any related diagnostic testing
except as provided by a
hospital as part of a covered inpatient stay or through an approved home
health care program
All charges All charges 32
32 Page 33 34
2001 Blue Cross
and Blue Shield Service Benefit Plan 33 Section 5( a)
Hearing
services (testing, treatment, and supplies) You pay – Standard Option You
pay – High Option
Hearing tests related to illness or injury
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance, plus
any difference between
our allowance and the
physician's actual charge
Preferred: 5% of the Plan allowance
Participating: 20% of the Plan
allowance
Non-participating: 20% of the Plan allowance,
plus any difference between
our allowance
and the physician's actual charge
Not covered:
= Routine hearing tests (except as indicated under
Preventive care, children)
= Hearing aids (including implanted bone conduction hearing aids)
= Testing and examinations for the prescribing or fitting of hearing
aids
All charges All charges
Vision services (testing, treatment, and supplies) You pay –
Standard Option You pay – High Option
= One pair of eyeglasses,
replacement lenses, or contact lenses to correct an impairment
directly
caused by a single instance of accidental ocular injury or intraocular surgery
Note: This benefit may also be used to obtain one pair of eyeglasses
or lenses prescribed in lieu of
surgery when the condition can be corrected
by surgery, but surgery is precluded because of age or
medical condition.
= Eye examinations related to a specific medical condition
= Nonsurgical treatment for amblyopia and strabismus, for children from birth
through
age 12
Note: See Section 5( b), Surgical procedures,
for coverage for surgical treatment of amblyopia and
strabismus.
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus
any
difference between our allowance and the
physician's actual charge
Preferred: 5% of the Plan allowance
Participating: 20% of the Plan
allowance
Non-participating: 20% of the Plan allowance,
plus any
difference between our allowance
and the physician's actual charge
Vision services – Continued on next page 33
33 Page 34 35
2001 Blue Cross and Blue Shield Service Benefit
Plan 34 Section 5( a)
Vision services (testing, treatment, and
supplies) -
Continued
You pay – Standard Option You
pay – High Option
Not covered:
= Eyeglasses, contact lenses, routine eye
examinations or vision testing for the
prescribing or fitting of eyeglasses or contact lenses, except as
described on page 33
= Eye exercises, visual training or orthoptics, except for nonsurgical
treatment of
amblyopia and strabismus as described on page 33
= Radial keratotomy and other refractive services
All charges All charges
Foot care You pay – Standard Option You pay – High Option
Routine foot care when you are under active treatment for a metabolic or
peripheral vascular
disease, such as diabetes
Note: See
orthopedic and prosthetic devices for information on podiatric shoe inserts.
Preferred: $15 copayment for the office visit (No
deductible); 10% of the
Plan allowance for all other
services (deductible applies)
Participating: 25% of the Plan allowance
Non-participating: 25% of the
Plan allowance, plus any
difference between our allowance and the
physician's
actual charge
Preferred: $12 copayment for the office visit (No
deductible); 5% of the
Plan allowance for all
other services (deductible applies)
Participating: 20% of the Plan allowance
Non-participating: 20% of the
Plan allowance, plus
any difference between our allowance and the
physician's actual charge
Not covered:
= Routine foot care, such as 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
All charges All charges 34
34 Page 35 36
2001 Blue Cross
and Blue Shield Service Benefit Plan 35 Section 5( a)
Orthopedic and prosthetic devices You pay – Standard Option You
pay – High Option
Orthopedic braces and prosthetic appliances such
as:
= Artificial limbs and eyes
= Functional foot orthotics when prescribed
by a physician
= Rigid devices attached to the foot or a brace, or placed in a shoe
=
Replacement, repair and adjustment of covered devices
= Following a
mastectomy, externally worn breast prostheses and surgical bras, including
necessary replacements
Note: A prosthetic appliance is a
device that is surgically inserted or physically attached to the
body to restore a bodily function or replace a physical portion of the body.
We provide hospital benefits for internal prosthetic devices, such as
artificial joints,
pacemakers, cochlear implants, and surgically implanted
breast implants following mastectomy;
see Section 5( c) for payment
information. Insertion of the device is paid as surgery; see
Section 5( b).
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus
any
difference between our allowance and the
provider's actual charge
Preferred: 5% of the Plan allowance
Participating: 20% of the Plan
allowance
Non-participating: 20% of the Plan allowance,
plus any
difference between our allowance
and the provider's actual charge
Not covered:
= Shoes and over-the-counter orthotics
=
Arch supports
= Heel pads and heel cups
= Penile
implants
= Wigs
= Implanted bone conduction hearing aids
All charges All charges 35
35 Page 36 37
2001 Blue Cross
and Blue Shield Service Benefit Plan 36 Section 5( a)
Durable
medical equipment (DME) You pay – Standard Option You pay – High
Option
Durable medical equipment (DME) is equipment and supplies that:
1. Are prescribed by your attending physician (i. e., the physician who is
treating your illness or
injury);
2. Are medically necessary;
3. Are
primarily and customarily used only for a medical purpose;
4. Are generally useful only to a person with an illness or injury;
5.
Are designed for prolonged use; and
6. Serve a specific therapeutic purpose
in the treatment of an illness or injury.
We cover rental or purchase, at our option, including repair and adjustment,
of durable medical equipment,
such as oxygen and home dialysis equipment.
Under this benefit, we also cover:
= Hospital beds
= Wheelchairs
= Crutches
= Walkers
= Other
items that we determine to be DME
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus
any difference between
our allowance and the
provider's actual charge
Preferred: 5% of the Plan allowance
Participating: 20% of the Plan
allowance
Non-participating: 20% of the Plan allowance,
plus any difference between
our allowance
and the provider's actual charge
Not covered:
= Exercise and bathroom equipment
=
Lifts, such as seat, chair or van lifts
= Car seats
=
Air conditioners, humidifiers, dehumidifiers and purifiers
= Breast pumps
= Computer "story boards" or
"light talkers" for communication-impaired individuals
= Equipment for cosmetic purposes
All charges All charges 36
36 Page 37 38
2001 Blue Cross
and Blue Shield Service Benefit Plan 37 Section 5( a)
Medical
supplies You pay – Standard Option You pay – High Option
=
Medical foods for children with inborn errors of amino acid metabolism
= Ostomy and catheter supplies
= Oxygen, regardless of the provider
=
Blood and blood plasma except when donated or replaced, and blood plasma
expanders
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus
any difference between
our allowance and the
provider's actual charge
Preferred: 5% of the Plan allowance
Participating: 20% of the Plan
allowance
Non-participating: 20% of the Plan allowance,
plus any difference between
our allowance
and the provider's actual charge
Home health services You pay – Standard Option You pay – High
Option
Home nursing care for two (2) hours per day, up to 25 visits per
calendar year under Standard Option
and 50 visits per calendar year under High Option, when:
= A registered nurse (R. N.) or licensed practical nurse (L. P. N.) provides
the services; and
= A physician orders the care
Note: Visits that
you pay for while meeting your calendar year deductible count toward the limits
cited
above.
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus
any difference between
our allowance and the
provider's actual charge
Preferred: 5% of the Plan allowance
Participating: 20% of the Plan
allowance
Non-participating: 20% of the Plan allowance,
plus any difference between
our allowance
and the provider's actual charge
Not covered:
= Nursing care requested by, or for the
convenience of, the patient or the patient's family
= Nursing care primarily for bathing, feeding, exercising, moving the
patient, homemaking,
giving medication, or acting as a companion or sitter
All charges All charges 37
37 Page 38 39
2001 Blue Cross
and Blue Shield Service Benefit Plan 38 Section 5( a)
Alternative treatments You pay – Standard Option You pay
– High Option
Acupuncture – when performed and billed by a
physician or licensed physical therapist, for:
= pain relief, and
= as a modality of physical therapy
Note: See page 32 for limitations.
Note: We may also cover
services of certain alternative treatment providers in medically
underserved areas. See page 10 for additional information.
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus
any difference between
our allowance and the
provider's actual charge
Preferred: 5% of the Plan allowance
Participating: 20% of the Plan
allowance
Non-participating: 20% of the Plan allowance,
plus any difference between
our allowance
and the provider's actual charge
Not covered:
Services you receive from non-covered providers
such as:
chiropractors
naturopaths
hypnotherapists
=
Biofeedback (or other forms of self-care or self-help training)
All charges All charges
Educational classes and programs You pay – Standard Option You pay
– High Option
Coverage is limited to:
= Smoking
cessation— enrollment in one smoking cessation program per member per
lifetime
Note: Services may be provided by any covered provider or
by a smoking cessation clinic.
See Section 5( f) for our coverage for smoking cessation drugs
You pay all charges after we pay $100 per member, per
lifetime (calendar
year deductible applies)
You pay all charges after we pay $100 per member,
per
lifetime (calendar year deductible applies)
= Diabetic education when billed by a covered provider
Note: We
cover diabetic educators, dieticians, and nutritionists who bill independently
only as part of a
covered diabetic education program.
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the physician's
actual charge
Preferred: 5% of the Plan allowance
Participating: 20% of the Plan
allowance
Non-participating: 20% of the Plan allowance, plus any
difference between our allowance and the
physician's actual charge
Educational classes and programs – Continued on next page 38
38 Page 39 40
2001 Blue Cross and Blue Shield Service Benefit
Plan 39 Section 5( a)
Educational classes and programs
-
Continued
You pay – Standard Option You pay –
High Option
Not covered:
= Marital, family, educational or other counseling
or training services when performed as part of an
educational class or program
= Premenstrual (PMS), lactation,
headache, eating disorder and other educational clinics
= Recreational or educational therapy, and any related diagnostic testing
except as provided by a
hospital as part of a covered inpatient stay or
through an approved home health care program
= Services performed or billed by a school or halfway house or a member of
its staff
All charges All charges 39
39 Page 40 41
2001 Blue Cross
and Blue Shield Service Benefit Plan 40 Section 5( b)
Section
5 (b). Surgical and anesthesia services provided by physicians and other health
care professionals
I M
P O
R T
A N
T
Here are some important things you should keep in mind about these
benefits:
= Please remember that all benefits are subject to the
definitions, limitations and exclusions in this brochure and are payable only
when we determine they are medically necessary.
= The calendar year deductible is: $250 per person ($ 500 per family) under
Standard Option and $150 per person ($ 300 per family) under High
Option. The Calendar Year deductible
applies to almost all benefits
under Standard Option in this Section. We added "( No deductible)" to
show when the calendar year deductible does not apply.
= Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works, with special sections for
members who are age 65 or over. Also
read Section 9 about coordinating
benefits with other coverage, including Medicare.
= The amounts listed below
are for the charges billed by a physician or other health care professional for
your surgical care. Look in Section 5( c) for charges associated with the
facility (i. e., hospital, surgical center, etc.).
= YOU MUST GET
PRIOR APPROVAL for all organ transplant surgical procedures; and if your
surgical procedure requires an inpatient admission, YOU MUST GET
PRECERTIFICATION. Please refer to the prior approval and precertification
information shown in Section 3 to be sure which services require prior approval
or
precertification.
= The non-PPO benefits are the standard
benefits of this Plan. PPO benefits apply only when you use a PPO provider. When
no PPO provider is available, non-PPO benefits apply.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in
this Section. We say "No deductible" when it does not apply.
Surgical procedures You pay – Standard Option You pay – High
Option
We pay for the following services provided, or ordered, and
billed by a physician:
= Operative procedures
= Treatment of fractures and dislocations,
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 on page 42)
= Treatment of burns
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus any
difference between
our allowance and the physician's
actual charge
Preferred: 5% of the Plan allowance
(No deductible)
Participating:
20% of the Plan allowance (No
deductible)
Non-participating: 20% of the Plan allowance (No
deductible), plus any
difference between our
allowance and the physician's actual charge
Surgical procedures – Continued on next page 40
40 Page 41 42
2001 Blue Cross and Blue Shield Service Benefit
Plan 41 Section 5( b)
Surgical procedures –
Continued You pay – Standard Option You pay – High Option
= Insertion of internal prosthetic devices. See Section 5( a) –
Orthopedic and prosthetic devices,
and Section 5( c) – Other hospital services and supplies – for
our coverage for the device.
= Voluntary sterilization, Norplant (a surgically implanted contraceptive),
and intrauterine devices
(IUDs)
= Assistant surgeons/ surgical
assistance by a physician if required because of the complexity
of the surgical procedures
= Gastric bypass surgery or gastric stapling
procedures for morbid obesity – a condition in
which an individual weighs 100 pounds over, or 100% over, his or her normal
weight according to
current underwriting standards; eligible members must be
age 18 or over
When multiple surgical procedures that add time or complexity to patient care
are performed during the
same operative session, the Local Plan determines
our allowance for the combination of multiple, bilateral,
or incidental
surgical procedures. Generally, we will allow a reduced amount for procedures
other than the
primary procedure.
Note: We do not pay extra for
"incidental" procedures (those that do not add time or
complexity to patient care).
Note: When unusual circumstances
require the removal of casts or sutures by a physician other than
the one who applied them, the Local Plan may determine that a separate
allowance is payable.
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus any
difference between
our allowance and the
physician's actual charge
Preferred: 5% of the Plan allowance (No
deductible)
Participating:
20% of the Plan allowance (No
deductible)
Non-participating: 20% of the Plan allowance (No
deductible), plus any difference between our
allowance and the
physician's actual charge
Not covered:
= Reversal of voluntary sterilization
=
Services of a standby physician
= Routine surgical treatment of
conditions of the foot (see Section 5( a) – Foot care)
= Cosmetic surgery
= Radial Keratotomy and other refractive
surgery
All charges All charges 41
41 Page 42 43
2001 Blue Cross
and Blue Shield Service Benefit Plan 42 Section 5( b)
Reconstructive surgery You pay – Standard Option You pay
– High Option
= Surgery to correct a functional defect
=
Surgery to correct a congenital anomaly – 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; and webbed fingers and
toes.
Note: Congenital anomalies do
not include conditions related to the teeth or intra-oral
structures supporting the teeth.
= Treatment to restore the mouth to a
pre-cancer state
= All stages of breast reconstruction surgery following a mastectomy, such
as:
surgery to produce a symmetrical appearance on the other breast
treatment of any physical complications, such as lymphedemas
Note: Internal breast prostheses are paid as medical services and
supplies [see Section 5( a)], or hospital
services [see Section 5( c)].
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.
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the
physician's actual charge
Preferred: 5% of the Plan allowance
(No deductible)
Participating:
20% of the Plan allowance (No
deductible)
Non-participating: 20% of the
Plan allowance (No
deductible), plus any difference between our
allowance and the physician's actual charge
Not covered:
= Cosmetic surgery – any operative procedure
or any portion of a procedure performed primarily to
improve physical appearance through change in bodily form –unless
required for a congenital
anomaly or to restore or correct a part of the
body that has been altered as a result of accidental
injury, disease or
surgery (does not include anomalies related to the teeth or structures
supporting the teeth)
= Surgeries related to sex transformation,
sexual dysfunction or sexual inadequacy
All charges All charges 42
42 Page 43 44
2001 Blue Cross
and Blue Shield Service Benefit Plan 43 Section 5( b)
Oral and
maxillofacial surgery You pay – Standard Option You pay – High
Option
Oral surgical procedures, limited to:
= Excision of tumors
and cysts of the jaws, cheeks, lips, tongue, roof and floor of mouth when
pathological examination is necessary
= Surgery needed to correct
accidental injuries (see Definitions) to jaws, cheeks, lips, tongue, roof and
floor of mouth
= Excision of exostoses of jaws and hard palate
=
External incision and drainage of cellulitis
= Incision and surgical
treatment of accessory sinuses, salivary glands or ducts
= Reduction of dislocations and excision of temporomandibular joints
=
Removal of impacted teeth
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus any
difference between
our allowance and the
physician's actual charge
Preferred: 5% of the Plan allowance (No deductible)
Participating: 20% of
the Plan allowance (No
deductible)
Non-participating: 20% of the Plan
allowance (No
deductible), plus any difference between our
allowance and
the physician's actual charge
Not covered:
= Oral implants and transplants
=
Surgical procedures that involve the teeth or their supporting structures
(such as the
periodontal membrane, gingiva, and alveolar bone), except as shown above
and in Section
5( h)
= Surgical procedures involving orthodontic
care, dental implants or preparation of the
mouth for the fitting or the continued use of dentures, except as
specifically shown above
and in Section 5( h)
All charges All charges
Organ/ tissue transplants You pay – Standard Option You pay –
High Option
= Cornea
= Heart
= Heart-lung
= Kidney
= Liver
= Pancreas
= Small bowel
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Preferred: 5% of the Plan allowance (No deductible)
Participating: 20% of the Plan allowance (No
deductible)
= Single or
double lung: only for the following end-stage pulmonary diseases: pulmonary
fibrosis, primary pulmonary hypertension, and emphysema
= Double lung: only for patients with end-stage cystic fibrosis
Non-participating: 25% of the Plan allowance, plus any
difference between
our allowance and the
physician's actual charge
Non-participating: 20% of the Plan allowance (No
deductible), plus any
difference between our
allowance and the physician's actual charge
Organ/ tissue transplants – Continued on next page 43
43 Page 44 45
2001 Blue Cross and Blue Shield Service Benefit
Plan 44 Section 5( b)
Organ/ tissue transplants –
Continued You pay – Standard Option You pay – High
Option
Bone marrow and stem cell transplants, limited to:
=
Allogeneic bone marrow transplants and allogeneic cord blood stem cell
transplants (from related or
unrelated donors) for:
Advanced neuroblastoma
Infantile malignant
osteopetrosis
Severe combined immunodeficiency
Wiskott-Aldrich syndrome
Mucopolysaccharidosis (e. g., Hunter, Hurler's, Sanfilippo, Maroteaux-Lamy
variants)
Mucolipidosis (e. g., Gaucher's disease, metachromatic leukodystrophy,
adrenoleukodystrophy)
Severe or very severe aplastic anemia
Thalassemia major (homozygous beta-thalassemia)
Sickle cell anemia
Phagocytic deficiency diseases
= Allogeneic bone
marrow transplants, allogeneic cord blood stem cell transplants (from related or
unrelated donors) and allogeneic peripheral blood stem cell transplants for:
Acute lymphocytic or non-lymphocytic (i. e., myelogenous) leukemia
Advanced Hodgkin's lymphoma
Advanced non-Hodgkin's lymphoma
Chronic
myelogenous leukemia
Advanced forms of myelodysplastic syndromes
=
Autologous bone marrow transplants and autologous peripheral blood stem cell
transplants
(collectively referred to as autologous stem cell support) for:
Acute lymphocytic or nonlymphocytic (i. e., myelogenous) leukemia
Advanced Hodgkin's lymphoma
Advanced non-Hodgkin's lymphoma
Advanced
neuroblastoma
Testicular, Mediastinal, Retroperitoneal and Ovarian germ cell
tumors
Multiple myeloma
Preferred: 10% of the Plan allowance
Participating: 25% of the Plan
allowance
Non-participating: 25% of the Plan allowance, plus any
difference between
our allowance and the physician's
actual charge
Preferred: 5% of the Plan allowance (No deductible)
Participating: 20% of
the Plan allowance (No
deductible)
Non-participating: 20% of the Plan
allowance (No
deductible), plus any difference between our
allowance and the
physician's actual charge
Organ/ tissue transplants – Continued on next page 44
44 Page 45 46
2001 Blue Cross and Blue Shield Service Benefit
Plan 45 Section 5( b)
Organ/ tissue transplants –
Continued You pay – Standard Option You pay – High
Option
= Extraction or reinfusion of bone marrow, blood stem cells, or
cord blood as a source of stem cells
as part of a covered allogeneic or autologous bone marrow transplant or blood
stem cell transplant
support procedure
= Marrow harvesting in
anticipation of a covered autologous bone marrow transplant, for patients
diagnosed at the time of harvesting with one of the conditions listed above
= Collection, processing, storage and distribution of cord blood only when
performed by a cord blood
bank approved by the FDA
= Storage of
harvested bone marrow, blood stem cells, or cord blood as a source of stem
cells, only
when a covered transplant has already been scheduled
= Related medical and hospital expenses of the donor, as part of a covered
transplant procedure
= Related services or supplies provided to the
recipient
Note: See Section 5( a) for coverage for related services,
such as chemotherapy and/ or radiation therapy and drugs
administered to stimulate or mobilize stem cells for covered transplant
procedures.
Limitations
(1) You must obtain prior approval (see page 14) from
the Local Plan, for both the procedure and the facility, for
the following transplant procedures:
= Bone marrow, cord blood stem cell
and peripheral blood stem cell transplant support
procedures
= Heart
= Heart-lung
= Liver
= Lung (single/
double)
= Pancreas
= Small bowel
See page 44 See page 44
Organ/ tissue transplants – Continued on next page 45
45 Page 46 47
2001 Blue Cross and Blue Shield Service Benefit
Plan 46 Section 5( b)
Organ/ tissue transplants
---Continued You pay – Standard Option You pay – High
Option
(2) For the following procedures, we provide benefits only
when conducted at a Cancer Research Facility
and performed as part of a clinical trial that meets the requirements shown
below:
= Allogeneic bone marrow transplants, syngeneic bone marrow transplants, and
allogeneic
peripheral blood stem cell transplants for:
Multiple myeloma
Chronic lymphocytic leukemia
Early stage (indolent or non-advanced)
small cell lymphocytic lymphoma
= Autologous bone marrow transplants and autologous peripheral blood stem
cell transplants
(collectively referred to as autologous stem cell support)
for:
Breast cancer
Epithelial ovarian cancer
Chronic myelogenous leukemia
Chronic lymphocytic leukemia
Early stage (indolent or non-advanced)
small cell lymphocytic lymphoma
For these bone marrow transplant procedures and related services or supplies
covered only through
clinical trials:
1. You must contact our Clinical
Trials Information Unit at 1-800-225-2268 for prior approval (see
page 14);
2. The clinical trial must be reviewed and approved by the
Institutional Review Board of the Cancer
Research Facility where the procedure is to be delivered; and
3. The patient must be properly and lawfully registered in the clinical
trial, meeting all the
eligibility requirements of the trial.
If a
non-randomized clinical trial meeting these requirements is not available at a
Cancer Research