ALABAMA STATE UNIVERSITY
HEALTH BENEFITS
BLUE CROSS BLUE SHIELD OF ALABAMA (BCBS)
GROUP #88942
INPATIENT HOSPITAL AND PHYSICIAN BENEFITS
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Preadmission Certification is required for inpatient admissions (except maternity): notification within 48 hours for emergencies. Call 1-800-248-2342 (toll free) for precertification.
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Blue Card PPO extends your PMD benefits outside of Alabama. This is important for employees who travel or have dependents attending college outside of Alabama. BCBS will issue the new cards to your home. Providers can be located at www.bcbsal.org or by calling BCBS at 1-800-810-BLUE.
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BENEFITS
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IN-NETWORK
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OUT-OF-NETWORK
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Inpatient Hospital
Note: Inpatient hospital deductibles and copays do not apply to the calendar year out-of-pocket maximum
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100% of the allowed amount, subject to a $100 deductible per admission and a $50 copayment for the 2nd through the 6th days.
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80% of the allowed amount, subject to a $200 deductible per admission.
Note: In Alabama, Out-of-Network benefits available only for accidental injury.
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Inpatient Physician Visits & Consultations
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Covered at 100%; no copay or deductible.
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Covered at 80%; subject to calendar year deductible.
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OUTPATIENT HOSPITAL BENEFITS
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BENEFITS
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IN-NETWORK
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OUT-OF-NETWORK
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Outpatient Surgery
(Including Ambulatory Surgical Centers)
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Covered at 100% after $25 facility copay.
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Covered at 80%; subject to calendar year deductible.
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Emergency Room
(Medical Emergency)
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Covered at 100% after $25 facility copay.
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Covered at 80%; subject to calendar year deductible; in Alabama, not covered.
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Emergency Room
(Accident)
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Covered at 100%; no copay or deductible.
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Covered at 100%; no copay or deductible for services within 72 hours; thereafter 80% subject to calendar year deductible.
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Emergency Room Physician
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Covered at 100% after $30 physician copay.
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Covered at 80%; subject to calendar year deductible.
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Outpatient Diagnostic Lab, X-Ray, Pathology, IV Therapy, Chemotherapy & Radiation Therapy
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Covered at 100%; no copay or deductible.
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Covered at 80%; subject to calendar year deductible.
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Dialysis
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Covered at 100%; no copay or deductible.
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Covered at 80%; subject to calendar year deductible.
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PHYSICIAN BENEFITS
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BENEFITS
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IN-NETWORK
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OUT-OF-NETWORK
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Office Visits & Consultations
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Covered at 100% after $30 physician copay.
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Covered at 80%; subject to calendar year deductible.
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Surgery & Anesthesia
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Covered at 100%; no copay or deductible.
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Covered at 80%; subject to calendar year deductible.
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Maternity Care
(Office visit copay applies to initial visit to confirm pregnancy).
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Covered at 100%; no copay or deductible.
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Covered at 80%; subject to calendar year deductible.
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Diagnostic Lab, X-Ray, Pathology, IV Therapy, Chemotherapy & Radiation Therapy
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Covered at 100%; no copay or deductible.
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Covered at 80%; subject to calendar year deductible.
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Note: In Alabama, Out-of-Network physician services covered at 50%; subject to calendar year deductible.
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PREVENTIVE CARE SERVICES
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BENEFITS
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IN-NETWORK
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OUT-OF-NETWORK
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Routine Newborn Care
(In Hospital)
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Covered at 100%; no copay or deductible.
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Not covered.
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Routine Well Child Care Exams
(Nine visits during first 24 months of life and one visit each year thereafter through age six).
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Covered at 100%; no deductible, subject to a $30 copayment.
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Not covered.
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Routine Immunizations
(Age limitations apply to certain immunizations).
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Covered at 100%; no copay or deductible.
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Not covered.
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Routine Office Visits
(When eligible for routine pap smear, routine mammogram, or routine PSA).
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Covered at 100% after $30 physician copay.
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Not covered.
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Routine Pap Smears
(One per year).
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Covered at 100%; no copay or deductible.
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Not covered.
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Routine/Screening Mammograms
(One exam for females ages 35-39 and one per year for females ages 40 and over).
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Covered at 100%; no copay or deductible.
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Not covered.
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Routine PSA (Prostate Specific Antigen)
(One per year for males age 40 and over).
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Covered at 100%; no copay or deductible.
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Not covered.
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Ages 50 and Over
*Hemocult spool check/fecal blood
*Test each year
*Flexible sigmoidoscopy every three years
*Double-contrast barium enema every five years
*Routine Colorectal Cancer Screening
*Colonoscopy every ten years
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Covered at 100%; no copay or deductible for physician changes.
(Outpatient hospital services may require a copay).
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Not covered.
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Note: In case of illness or family history of cancer, services generally are not considered preventive and may be covered by the other plan provisions.
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PRESCRIPTION AND DRUG BENEFITS
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BENEFITS
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IN-NETWORK
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OUT-OF-NETWORK
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Preferred Rx Products
Non-maintenance – up to a 30 day supply.
Blue Cross Maintenance List Drugs – up to a 60 day supply.
Some copays combined for diabetic supplies.
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Generic Drugs:
$10 copay per prescription
Preferred Brand Name Drugs:
$30 copay per prescription
Other Brand Name Drugs:
$50 copay per prescription
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No benefits available.
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Note: To view the most current Preferred Drug List or Maintenance Drug List, visit www.bcbsal.org. Then select “I am a Customer,” and on the next screen under Prescription Drug Reference, select “Prescription Drug Guide.”
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SUMMARY OF COST SHARING PROVISIONS
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Calendar Year Deductible Applies to:
Out-of-Network Home Health and Hospice.
Other covered services.
Out-of-Network physician services.
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$200 individual; $600 aggregate maximum per family.
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Calendar Year Out-of-Pocket Maximum Applies to:
Other Covered Services:
Inpatient Physician services for mental health and substance abuse treatment.
Out-of-network physician services outside of Alabama.
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$400 individual; certain benefits pay at 100% of the allowed amount thereafter.
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Lifetime Maximum Applies to:
Other Covered Services:
Out-of-Network physician services.
Out-of-Network outpatient hospital services.
Physician services for the treatment of mental health and substance abuse.
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$1,000,000 per individual.
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BENEFITS FOR OTHER COVERED SERVICES
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BENEFITS
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IN-NETWORK
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OUT-OF-NETWORK
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Allergy Testing & Treatment
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Covered at 80%; subject to calendar year deductible.
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Covered at 80%; subject to calendar year deductible.
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Ambulance Services
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Covered at 80%; subject to calendar year deductible.
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Covered at 80%; subject to calendar year deductible.
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Participating Chiropractor Services
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Covered at 80%; subject to calendar year deductible.
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Covered at 80%; subject to calendar year deductible; in Alabama, covered at 50%; subject to calendar year deductible.
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Durable Medical Equipment
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Covered at 80%; subject to calendar year deductible.
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Covered at 80%; subject to calendar year deductible; in Alabama, covered at 50%; subject to calendar year deductible.
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Occupational and Physical Therapy
(Occupational, physical and speech therapy limited to a combined maximum of 30 visits per year).
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Covered at 80%; subject to calendar year deductible.
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Covered at 80%; subject to calendar year deductible; in Alabama, covered at 50%; subject to calendar year deductible.
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Speech Therapy
(Occupational, physical and speech therapy limited to a combined maximum of 30 visits per year).
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Covered at 80%; subject to calendar year deductible.
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Covered at 80%; subject to calendar year deductible; in Alabama, covered at 50%; subject to calendar year deductible.
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HOME HEALTH AND HOSPICE
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BENEFITS
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IN-NETWORK
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OUT-OF-NETWORK
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Preferred Home Health and Hospice
Precertification required for visits by home health professional outside Alabama.
For Precertification, call
1-800-821-7231.
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Covered at 100%; no copay or deductible.
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Outside Alabama; Precertification required; 80% of allowed amount subject to calendar year deductible.
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SUPPLEMENTAL ACCIDENTAL BENEFITS
Accident Rider 400 and Diagnostic Lab Rider
280 benefits are being discontinued
MENTAL HEALTH & SUBSTANCE ABUSE BENEFITS
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BENEFITS
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IN-NETWORK
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OUT-OF-NETWORK
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Inpatient Hospital
Up to 15 days per person each 12 consecutive months; no coverage after 15 days.
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Covered at 100%; subject to $100 deductible per admission and a $50 per day copayment beginning with the 2nd day through the 6th day.
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80% of the allowed amount covered; subject to a $200 deductible per admission.
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Inpatient Physician Services
Up to 15 days of inpatient treatment during any 12 consecutive months; no coverage after 15 days.
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Covered at 100%; no deductible.
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80% covered; subject to the calendar year deductible.
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Outpatient Hospital & Physician
Limited to 20 visits per person each calendar year.
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Covered at 50%; subject to calendar year deductible.
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50% of the allowed amount covered; subject to the calendar year deductible.
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HEALTH MANAGEMENT BENEFITS
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Individual Case Management
Alternative benefits through individual Case Management may be available for your condition.
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Coordinates care in event of catastrophic or lengthy illness or injury.
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Disease Management
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Coordinates care for chronic conditions such as asthma, diabetes, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease.
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Baby Yourself
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Prenatal wellness program; coordinates high-risk pregnancy early intervention.
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MAXIMIZE BENEFITS BY USING IN-NETWORK PROVIDERS
· To find In-Network providers, check a preferred provider (PMD) Directory, Provider Finder Website (www.bcbsal.org) or call 1-800-292-8868.
· Out-of-Network providers generally do not contract with Blue Cross/Blue Shield plans. If you use Out-of-Network providers, you may be responsible for filing your own claims and paying the difference between the provider’s charges for care in the area.
· Please be aware that provider’s/specialists may be listed in PPO directory or provider finder website, but not covered under this benefit plan. Please check your benefit booklet for more detailed coverage information.