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Medical Benefits

Health Benefits – Blue Cross Blue Shield of Alabama (BCBS) - Group #88942

CURRENT BCBS PLAN

HEALTH PLAN CHANGES

(Effective 1/1/2017)

Emergency Room (Medical Emergency):Covered at 100% after $25 copay

Emergency Room (Medical Emergency): Covered at 100% after $100 copay
Emergency Room (Accident): Covered at 100%: no copay or deductible Emergency Room (Accident): Covered at 100% after $100 hosptial copay
Inpatient Hospital: Covered at 100% after $100 per admission deductible; $50/day hospital copay days 2-6 for each admission Inpatient Hospital: Covered at 100% of the allowed amount, subject to the calendar year deductible; $50/day copays days 2-6 for each admission
Outpatient Surgery: Covered at 100% after $25 hospital copay Outpatient Surgery: Covered at 100% after $250 hospital copay
Outpatient Physician Office Visits: $30 copay Outpatient Physician Office Visits: $35 copay (Primary Care); $50 copay (Specialist)
Coinsurance is 20% Coinsurance is 100%
Out of pocket max $400 Individual Out of pocket Max $1500 Individual ($4500 Family)
Copays and Deductible DO NOT apply to OOP Max Copay and Deductible DO apply to OOP Max
   

Prescription Drug Benefits will now be covered by CVS Caremark.

 

Inpatient Hospital & Physician Benefits

Preadmission Certification is required for inpatient admissions (except maternity): notification within 48 hours for emergencies. Call 1-800-248-2342 (toll free) for precertification.

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.

Benefits In-Network Out-of-Network
Inpatient Hospital

Note:  Inpatient hospital deductibles and co-pays do not apply to the calendar year out-of-pocket maximum
100% of the allowed amount, subject to a $100 deductible per admission and a $50 copayment for the 2nd through the 6th days. 80% of the allowed amount, subject to a $200 deductible per admission.

Note:  In Alabama, Out-of-Network benefits available only for accidental injury.
Inpatient Physician Visits & Consultations Covered at 100%; no copay or deductible. Covered at 80%; subject to calendar year deductible.

Outpatient Hospital Benefits

Benefits In-Network Out-of-Network
Outpatient Surgery

(Including Ambulatory Surgical Centers)
Covered at 100% after $25 facility co-pay. Covered at 80%; subject to calendar year deductible.
Emergency Room

(Medical Emergency)
Covered at 100% after $25 facility co-pay. Covered at 80%; subject to calendar year deductible; in Alabama, not covered.
Emergency Room

(Accident)
Covered at 100%; no co-pay or deductible. Covered at 100%; no co-pay or deductible for services within 72 hours; thereafter 80% subject to calendar year deductible.
Emergency Room Physician Covered at 100% after $30 physician co-pay. Covered at 80%; subject to calendar year deductible.
Outpatient Diagnostic Lab, X-Ray, Pathology, IV Therapy, Chemotherapy & Radiation Therapy Covered at 100%; no co-pay or deductible. Covered at 80%; subject to calendar year deductible.
Dialysis Covered at 100%; no co-pay or deductible. Covered at 80%; subject to calendar year deductible.

Physician Benefits

Benefits In-Network  Out-of-Network
Office Visits & Consultations Covered at 100% after $30 physician co-pay. Covered at 80%; subject to calendar year deductible.
Surgery & Anesthesia Covered at 100%; no co-pay or deductible. Covered at 80%; subject to calendar year deductible.
Maternity Care

(Office visit co-pay applies to initial visit to confirm pregnancy).
Covered at 100%; no co-pay or deductible. Covered at 80%; subject to calendar year deductible.
Diagnostic Lab, X-Ray, Pathology, IV Therapy, Chemotherapy & Radiation Therapy Covered at 100%; no co-pay or deductible. Covered at 80%; subject to calendar year deductible.
Note: In Alabama, Out-of-Network physician services covered at 50%; subject to calendar year deductible.

Preventive Care Services

Benefits In-Network  Out-of-Network
Routine Newborn Care (In Hospital) Covered at 100%; no co-pay or deductible. Not covered.
Routine Well Child Care Exams

(Nine visits during first 24 months of life and one visit each year thereafter through age six).
Covered at 100%; no deductible, subject to a $30 copayment. Not covered.
Routine Immunizations

(Age limitations apply to certain immunizations).
Covered at 100%; no co-pay or deductible. Not covered.
Routine Office Visits (When eligible for routine pap smear, routine mammogram, or routine PSA). Covered at 100% after $30 physician co-pay. Not covered.
Routine Pap Smears (One per year). Covered at 100%; no co-pay or deductible. Not covered.
Routine/Screening Mammograms

(One exam for females ages 35-39 and one per year for females ages 40 and over).
Covered at 100%; no co-pay or deductible. Not covered.
Routine PSA (Prostate Specific Antigen) (One per year for males age 40 and over). Covered at 100%; no co-pay or deductible. Not covered.
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

 
Covered at 100%; no co-pay or deductible for physician changes.

(Outpatient hospital services may require a co-pay).
Not covered.
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.

Prescription & Drug Benefits

Benefits In-Network  Out-of-Network
Preferred Rx Products

Non-maintenance – up to a 30 day supply.

Blue Cross Maintenance List Drugs – up to a 60 day supply.

Some co-pays combined for diabetic supplies.
Generic Drugs:

$10 co-pay per prescription

Preferred Brand Name Drugs:

$30 co-pay per prescription

Other Brand Name Drugs:

$50 co-pay per prescription
No benefits available.
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.”

Summary of Cost Sharing Provisions

Calendar Year Deductible Applies to:

Out-of-Network Home Health and Hospice.

Other covered services.

Out-of-Network physician services.
$200 individual; $600 aggregate maximum per family.
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.
$400 individual; certain benefits pay at 100% of the allowed amount thereafter.
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.
$1,000,000 per individual.

Benefits for Other Covered Services

Benefits In-Network  Out-of-Network
Allergy Testing & Treatment Covered at 80%; subject to calendar year deductible. Covered at 80%; subject to calendar year deductible.
Ambulance Services Covered at 80%; subject to calendar year deductible. Covered at 80%; subject to calendar year deductible.
Participating Chiropractor Services Covered at 80%; subject to calendar year deductible. Covered at 80%; subject to calendar year deductible; in Alabama, covered at 50%; subject to calendar year deductible.
Durable Medical Equipment Covered at 80%; subject to calendar year deductible. Covered at 80%; subject to calendar year deductible; in Alabama, covered at 50%; subject to calendar year deductible.
Occupational and Physical Therapy (Occupational, physical and speech therapy limited to a combined maximum of 30 visits per year). Covered at 80%; subject to calendar year deductible. Covered at 80%; subject to calendar year deductible; in Alabama, covered at 50%; subject to calendar year deductible.
Speech Therapy  (Occupational, physical and speech therapy limited to a combined maximum of 30 visits per year). Covered at 80%; subject to calendar year deductible. Covered at 80%; subject to calendar year deductible; in Alabama, covered at 50%; subject to calendar year deductible.

Home Health & Hospice

Benefits In-Network  Out-of-Network
Preferred Home Health and Hospice

Precertification required for visits by home health professional outside Alabama.

For Precertification, call 1-800-821-7231.
Covered at 100%; no co-pay or deductible. Outside Alabama; Precertification required; 80% of allowed amount subject to calendar year deductible.

Supplemental Accidental Benefits

  • Accident Rider 400 and Diagnostic Lab Rider
  • 280 benefits are being discontinued

Mental Health & Substance Abuse Benefits

Benefits In-Network  Out-of-Network
Inpatient Hospital Up to 15 days per person each 12 consecutive months; no coverage after 15 days. Covered at 100%; subject to $100 deductible per admission and a $50 per day copayment beginning with the 2nd day through the 6th day. 80% of the allowed amount covered; subject to a $200 deductible per admission.
Inpatient Physician Services Up to 15 days of inpatient treatment during any 12 consecutive months; no coverage after 15 days. Covered at 100%; no deductible. 80% covered; subject to the calendar year deductible.
Outpatient Hospital & Physician Limited to 20 visits per person each calendar year. Covered at 50%; subject to calendar year deductible. 50% of the allowed amount covered; subject to the calendar year deductible.

Health Management Benefits

Individual Case Management

Alternative benefits through individual Case Management may be available for your condition.
Coordinates care in event of catastrophic or lengthy illness or injury.
Disease Management Coordinates care for chronic conditions such as asthma, diabetes, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease.
Baby Yourself Prenatal wellness program; coordinates high-risk pregnancy early intervention.

Maximize Benefits by Using In-Network Providers 

  • To find In-Network providers, check a preferred provider (PMD) Directory, Provider Finder Website 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.
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