Health Insurance Experts Analysts Randi

[kumar654]

Hi, naku ee deductables and in/out networks and other rules asalu emi idea ledu. oka sari emo doc dagagrikella regular checkup ki and they charged $20 co pay anthe telusu.

 

asalu deductables ela work chestay. ippudu manam blood tests n other cheyistam kada oka $1000 ayithe vallu andulo ela theesukuntaru. ippudu manam year lo oka $3000 worth medical tests cheyinchukunte asalu ela deduct avutay. ee plan lo nenu ma wife undi . below is the base plan from BCBS ma employer di

 

 

Member’s responsibility (deductibles, copays, coinsurance and dollar maximums)

Deductibles $5,000 for one member

$10,000 for the family (when two or more

members are covered under your contract)

each calendar year

Note: Deductible may be waived for

covered services performed in an innetwork

physician’s office.

$10,000 for one member

$20,000 for the family (when two or more

members are covered under your contract)

each calendar year

Note: Out-of-network deductible amounts

also count toward the in-network

deductible.

 

 

 

XXX company

Community Blue PPOSM LG

Medical Coverage

Benefits-at-a-Glance

Effective for groups on their plan year beginning on or after January 1, 2015

This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and

exclusions may apply. Payment amounts are based on BCBSM’s approved amount, less any applicable deductible and/or copay/coinsurance.

For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan

documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan

document, the plan document will control.

Preauthorization for Select Services – Services listed in this BAAG are covered when provided in accordance with Certificate requirements

and, when required, are preauthorized or approved by BCBSM except in an emergency.

Note: To be eligible for coverage, the following services require your provider to obtain approval before they are provided – select radiology

services, inpatient acute care, skilled nursing care, human organ transplants, inpatient mental health care, inpatient substance abuse treatment,

rehabilitation therapy and applied behavioral analyses.

Pricing information for various procedures by in-network providers can be obtained by calling the customer service number listed on the back of

your BCBSM ID card and providing the procedure code. Your provider can also provide this information upon request.

Preauthorization for Specialty Pharmaceuticals – BCBSM will pay for FDA-approved specialty pharmaceuticals that meet BCBSM’s medical

policy criteria for treatment of the condition. The prescribing physician must contact BCBSM to request preauthorization of the drugs. If

preauthorization is not sought, BCBSM will deny the claim and all charges will be the member’s responsibility.

Specialty pharmaceuticals are biotech drugs including high cost infused, injectable, oral and other drugs related to specialty disease categories

or other categories. BCBSM determines which specific drugs are payable. This may include medications to treat asthma, rheumatoid arthritis,

multiple sclerosis, and many other disease as well as chemotherapy drugs used in the treatment of cancer, but excludes injectable insulin.

In-network Out-of-network *

Member’s responsibility (deductibles, copays, coinsurance and dollar maximums)

Deductibles $5,000 for one member

$10,000 for the family (when two or more

members are covered under your contract)

each calendar year

Note: Deductible may be waived for

covered services performed in an innetwork

physician’s office.

$10,000 for one member

$20,000 for the family (when two or more

members are covered under your contract)

each calendar year

Note: Out-of-network deductible amounts

also count toward the in-network

deductible.

Flat-dollar copays • $20 copay for office visits and office

consultations

• $20 copay for chiropractic services and

osteopathic manipulative therapy

• $150 copay for emergency room visits

$150 copay for emergency room visits

Coinsurance amounts (percent copays)

Note: Coinsurance amounts apply once the

deductible has been met.

50% of approved amount for private duty

nursing care

• 50% of approved amount for private

duty nursing care

• 50% of approved amount for mental

health care and substance abuse

treatment

• 50% of approved amount for most other

covered services* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low

access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services

outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and

the provider’s charge.

Community Blue PPO LG – MAY 2014

In-network Out-of-network *

Member’s responsibility (deductibles, copays, coinsurance and dollar maximums), continued

Annual out-of-pocket maximums – applies to

deductibles, copays and coinsurance amounts for all

covered services – including cost-sharing amounts

for prescription drugs, if applicable

$6,350 for one member

$12,700 for two or more members

each calendar year

$12,700 for one member

$25,400 for two or more members

each calendar year

Note: Out-of-network cost-sharing

amounts also count toward the innetwork

out-of-pocket maximum.

Lifetime dollar maximum None

Preventive care services

Health maintenance exam – includes chest x-ray,

EKG, cholesterol screening and other select lab

procedures

100% (no deductible or copay/coinsurance),

one per member per calendar year

Note: Additional well-women visits may be

allowed based on medical necessity.

Not covered

Gynecological exam 100% (no deductible or copay/coinsurance),

one per member per calendar year

Note: Additional well-women visits may be

allowed based on medical necessity.

Not covered

Pap smear screening – laboratory and pathology

services

100% (no deductible or copay/coinsurance),

one per member per calendar year

Not covered

Voluntary sterilizations for females 100% (no deductible or copay/coinsurance) 50% after out-of-network deductible

Prescription contraceptive devices – includes

insertion and removal of an intrauterine device by a

licensed physician

100% (no deductible or copay/coinsurance) 100% after out-of-network deductible

Contraceptive injections 100% (no deductible or copay/coinsurance) 50% after out-of-network deductible

Well-baby and child care visits 100% (no deductible or copay/coinsurance)

• 6 visits, birth through 12 months

• 6 visits, 13 months through 23 months

• 6 visits, 24 months through 35 months

• 2 visits, 36 months through 47 months

• Visits beyond 47 months are limited to

one per member per calendar year under

the health maintenance exam benefit

Not covered

Adult and childhood preventive services and

immunizations as recommended by the USPSTF,

ACIP, HRSA or other sources as recognized by

BCBSM that are in compliance with the provisions

of the Patient Protection and Affordable Care Act

100% (no deductible or copay/coinsurance) Not covered

Fecal occult blood screening 100% (no deductible or copay/coinsurance),

one per member per calendar year

Not covered

Flexible sigmoidoscopy exam 100% (no deductible or copay/coinsurance),

one per member per calendar year

Not covered

Prostate specific antigen (PSA) screening 100% (no deductible or copay/coinsurance),

one per member per calendar year

Not covered

Routine mammogram and related reading 100% (no deductible or copay/coinsurance)

Note: Subsequent medically necessary

mammograms performed during the same

calendar year are subject to your deductible

and coinsurance.

50% after out-of-network deductible

Note: Out-of-network readings and

interpretations are payable only

when the screening mammogram

itself is performed by an in-network

provider.

One per member per calendar year* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low

access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services

outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and

the provider’s charge.

Community Blue PPO LG – MAY 2014

In-network Out-of-network *

Preventive care services, continued

Colonoscopy – routine or medically necessary 100% (no deductible or copay/coinsurance)

for the first billed colonoscopy

Note: Subsequent colonoscopies

performed during the same calendar year

are subject to your deductible and

coinsurance.

50% after out-of-network deductible

One per member per calendar year

Physician office services

Office visits – must be medically necessary $20 copay per office visit 50% after out-of-network deductible

Outpatient and home medical care visits –

must be medically necessary

100% after in-network deductible 50% after out-of-network deductible

Office consultations – must be medically necessary $20 copay per office visit 50% after out-of-network deductible

Urgent care visits – must be medically necessary $20 copay per office visit 50% after out-of-network deductible

Emergency medical care

Hospital emergency room $150 copay per visit (copay waived if

admitted or for an accidental injury)

$150 copay per visit (copay waived if

admitted or for an accidental injury)

Ambulance services – must be medically necessary 100% after in-network deductible 100% after in-network deductible

Diagnostic services

Laboratory and pathology services 100% after in-network deductible 50% after out-of-network deductible

Diagnostic tests and x-rays 100% after in-network deductible 50% after out-of-network deductible

Therapeutic radiology 100% after in-network deductible 50% after out-of-network deductible

Maternity services provided by a physician or certified nurse midwife

Prenatal care visits 100% (no deductible or copay/coinsurance) 50% after out-of-network deductible

Postnatal care visits 100% (no deductible or copay/coinsurance) 50% after out-of-network deductible

Delivery and nursery care 100% after in-network deductible 50% after out-of-network deductible

Hospital care

Semiprivate room, inpatient physician care, general

nursing care, hospital services and supplies

Note: Nonemergency services must be rendered in

a participating hospital.

100% after in-network deductible 50% after out-of-network deductible

Unlimited days

Inpatient consultations 100% after in-network deductible 50% after out-of-network deductible

Chemotherapy 100% after in-network deductible 50% after out-of-network deductible

Alternatives to hospital care

Skilled nursing care – must be in a

participating skilled nursing facility

100% after in-network deductible 100% after in-network deductible

Limited to a maximum of 120 days per member per calendar year

Hospice care 100% (no deductible or

copay/coinsurance)

100% (no deductible or

copay/coinsurance)

Up to 28 pre-hospice counseling visits before electing hospice services; when

elected, four 90-day periods – provided through a participating hospice program

only; limited to dollar maximum that is reviewed and adjusted periodically (after

reaching dollar maximum, member transitions into individual case management)

Home health care:

• must be medically necessary

• must be provided by a participating home health

care agency

100% after in-network deductible 100% after in-network deductible* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low

access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services

outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and

the provider’s charge.

Community Blue PPO LG – MAY 2014

In-network Out-of-network *

Alternatives to hospital care, continued

Infusion therapy:

• must be medically necessary

• must be given by a participating Home Infusion Therapy

(HIT) provider or in a participating freestanding

Ambulatory Infusion Center (AIC)

• may use drugs that require preauthorization – consult with

your doctor

100% after in-network deductible 100% after in-network deductible

Surgical services

Surgery – includes related surgical services and medically

necessary facility services by a participating ambulatory

surgery facility

100% after in-network deductible 50% after out-of-network deductible

Presurgical consultations 100% (no deductible or

copay/coinsurance)

50% after out-of-network deductible

Voluntary sterilization for males

Note: For voluntary sterilizations for females, see

“Preventive care services.”

100% after in-network deductible 50% after out-of-network deductible

Elective abortions For special circumstance – 100%

after in-network deductible; other

elective abortions are not covered

For special circumstance – 50% after

out-of-network deductible; other

elective abortions are not covered

Human organ transplants

Specified human organ transplants – must be in a

designated facility and coordinated through the BCBSM

Human Organ Transplant Program (1-800-242-3504)

100% (no deductible or

copay/coinsurance)

100% (no deductible or

copay/coinsurance) – in

designated facilities only

Bone marrow transplants – must be coordinated

through the BCBSM Human Organ Transplant

Program (1-800-242-3504)

100% after in-network deductible 50% after out-of-network deductible

Specified oncology clinical trials

Note: BCBSM covers clinical trials in compliance with

PPACA.

100% after in-network deductible 50% after out-of-network deductible

Kidney, cornea and skin transplants 100% after in-network deductible 50% after out-of-network deductible

Mental health care and substance abuse treatment

Note: Some mental health and substance abuse services are considered by BCBSM to be comparable to an office visit. When a mental

health and substance abuse service is considered by BCBSM to be comparable to an office visit, you pay only for an office visit as

described in your certificate or related riders.

This means when these services are performed by an in-network provider, you will have no in-network deductible. You will be responsible for

the flat-dollar member copay that applies to office visits. When these services are performed by an out-of-network provider, you will be

responsible for your annual out-of-network deductible and the coinsurance amount that applies to covered out-of-network services.

Inpatient mental health care and

inpatient substance abuse treatment

100% after in-network deductible 50% after out-of-network deductible

Unlimited days

Outpatient mental health care:

• Facility and clinic 100% after in-network deductible 100% after in-network deductible,

in participating facilities only

• Physician’s office 100% after in-network deductible 50% after out-of-network deductible

Outpatient substance abuse treatment – in approved

facilities only

100% after in-network deductible 50% after out-of-network deductible

(in-network cost-sharing will apply if

there is no PPO network)* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low

access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services

outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and

the provider’s charge.

Community Blue PPO LG – MAY 2014

In-network Out-of-network *

Autism spectrum disorders, diagnoses and treatment

Applied behavioral analysis (ABA) treatment – when

rendered by an approved board-certified behavioral analyst

– is covered through age 18, subject to preauthorization

Note: Diagnosis of an autism spectrum disorder and a

treatment recommendation for ABA services must be

obtained by a BCBSM approved autism evaluation center

(AAEC) prior to seeking ABA treatment.

100% after in-network deductible 100% after in-network deductible

Outpatient physical therapy, speech therapy, occupational

therapy, nutritional counseling for autism spectrum disorder

100% after in-network deductible 50% after out-of-network deductible

Physical, speech and occupational therapy with an autism diagnosis

is unlimited

Other covered services, including mental health services,

for autism spectrum disorder

100% after in-network deductible 50% after out-of-network deductible

Other covered services

Outpatient Diabetes Management Program (ODMP)

Note: Screening services required under the provisions of

PPACA are covered at 100% of approved amount with no

in-network cost-sharing when rendered by an in-network

provider.

Note: When you purchase your diabetic supplies via mail

order you will lower your out-of-pocket costs.

• 100% after in-network deductible

for diabetes medical supplies

• 100% (no deductible or

copay/coinsurance) for diabetes

self-management training

50% after out-of-network deductible

Allergy testing and therapy 100% (no deductible or

copay/coinsurance)

50% after out-of-network deductible

Chiropractic spinal manipulation and

osteopathic manipulative therapy

$20 copay per office visit 50% after out-of-network deductible

Limited to a combined 24-visit maximum per member per calendar year

Outpatient physical, speech and occupational therapy –

provided for rehabilitation

100% after in-network deductible 50% after out-of-network deductible

Note: Services at nonparticipating

outpatient physical therapy facilities

are not covered.

Limited to a combined 60-visit maximum per member per calendar year

Durable medical equipment

Note: DME items required under the provisions of PPACA

are covered at 100% of approved amount with no in-network

cost-sharing when rendered by an in-network provider. For a

list of covered DME items required under PPACA, call

BCBSM.

100% after in-network deductible 100% after in-network deductible

Prosthetic and orthotic appliances 100% after in-network deductible 100% after in-network deductible

Private duty nursing care 50% after in-network deductible 50% after in-network deductible* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low

access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services

outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and

the provider’s charge.

Community Blue PPO LG – MAY 2014

Blue Preferred® Rx LG Prescription Drug Coverage

3-Tier Copay, Open Formulary

Benefits-at-a-Glance

Effective for groups on their plan year beginning on or after January 1, 2015

This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations

and exclusions may apply. Payment amounts are based on BCBSM’s approved amount, less any applicable deductible, copay and /or

coinsurance. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or

any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any

applicable plan document, the plan document will control.

Specialty Pharmaceutical Drugs – The mail order pharmacy for specialty drugs is Walgreens Specialty Pharmacy, LLC, an independent

company. Specialty prescription drugs (such as Enbrel®

and Humira®

) are used to treat complex conditions such as rheumatoid arthritis,

multiple sclerosis and cancer. These drugs require special handling, administration or monitoring. Walgreens Specialty Pharmacy will handle

mail order prescriptions only for specialty drugs while many in-network retail pharmacies will continue to dispense specialty drugs (check with

your local pharmacy for availability). Other mail order prescription medications can continue to be sent to Express Scripts. (Express Scripts is

an independent company providing pharmacy benefit services for Blues members.) A list of specialty drugs is available on our Web site at

bcbsm.com/pharmacy. If you have any questions, please call Walgreens Specialty Pharmacy customer service at 1-866-515-1355.

We will not pay for more than a 30-day supply of a covered prescription drug that BCBSM defines as a “specialty pharmaceutical” whether or

not the drug is obtained from a 90-Day Retail Network provider or mail-order provider. We may make exceptions if a member requires more

than a 30-day supply. BCBSM reserves the right to limit the initial quantity of select specialty drugs. Your copay will be reduced by one-half for

this initial fill (15 days).

Member’s responsibility (copays)

Note: Your prescription drug copays, including mail order copays, are subject to the same annual out-of-pocket maximum required under

your medical coverage. The following prescription drug expenses will not apply to your annual out-of-pocket maximum:

• any difference between the Maximum Allowable Cost and BCBSM’s approved amount for a covered brand name drug

• the 25% member liability for covered drugs obtained from an out-of-network pharmacy

90-day retail

network

pharmacy

* In-network

mail order

provider

In-network pharmacy

(not part of the 90-day

retail network)

Out-of-network

pharmacy

Tier 1 –

Generic or

select

prescribed

over-thecounter

drugs

1 to 30-day period You pay $15 copay You pay $15 copay You pay $15 copay You pay $15 copay

plus an additional 25%

of BCBSM approved

amount for the drug

31 to 83-day period No coverage You pay $30 copay No coverage No coverage

84 to 90-day period You pay $30 copay You pay $30 copay No coverage No coverage

Tier 2 –

Preferred

brand-name

drugs

1 to 30-day period You pay $30 copay You pay $30 copay You pay $30 copay You pay $30 copay

plus an additional 25%

of BCBSM approved

amount for the drug

31 to 83-day period No coverage You pay $60 copay No coverage No coverage

84 to 90-day period You pay $60 copay You pay $60 copay No coverage No coverage

Tier 3 –

Nonpreferred

brand-name

drugs

1 to 30-day period You pay $60 copay You pay $60 copay You pay $60 copay You pay $60 copay

plus an additional 25%

of BCBSM approved

amount for the drug

31 to 83-day period No coverage You pay $120 copay No coverage No coverage

84 to 90-day period You pay $120 copay You pay $120 copay No coverage No coverage

Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select

prescription drugs. A prescription for the select OTC drug is required from the member’s physician. In some cases, over-the-counter drugs may

need to be tried before BCBSM will approve use of other drugs.

* BCBSM will not pay for drugs obtained from out-of-network mail order providers, including Internet providers.* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low

access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services

outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and

the provider’s charge.

Community Blue PPO LG – MAY 2014

Covered services

90-day retail

network

pharmacy

* In-network

mail order

provider

In-network pharmacy

(not part of the 90-day

retail network)

Out-of-network

pharmacy

FDA-approved drugs 100% of approved

amount less plan

copay

100% of approved

amount less plan

copay

100% of approved

amount less plan

copay

75% of approved

amount less plan

copay

Prescribed over-the-counter drugs –

when covered by BCBSM

100% of approved

amount less plan

copay

100% of approved

amount less plan

copay

100% of approved

amount less plan

copay

75% of approved

amount less plan

copay

State-controlled drugs 100% of approved

amount less plan

copay

100% of approved

amount less plan

copay

100% of approved

amount less plan

copay

75% of approved

amount less plan

copay

FDA-approved generic and select

brand name prescription preventive

drugs, supplements, and vitamins

(non-self-administered drugs are not

covered)

100% of approved

amount

100% of approved

amount

100% of approved

amount

75% of approved

amount

Other FDA-approved brand name

prescription preventive drugs,

supplements, and vitamins (non-selfadministered

drugs are not covered)

100% of approved

amount less plan

copay

100% of approved

amount less plan

copay

100% of approved

amount less plan

copay

75% of approved

amount less plan

copay

FDA-approved generic and select

brand name prescription contraceptive

medication (non-self-administered

drugs are not covered)

100% of approved

amount

100% of approved

amount

100% of approved

amount

75% of approved

amount

Other FDA-approved brand name

prescription contraceptive medication

(non-self-administered drugs are not

covered)

100% of approved

amount less plan

copay

100% of approved

amount less plan

copay

100% of approved

amount less plan

copay

75% of approved

amount less plan

copay

Disposable needles and syringes –

when dispensed with insulin or other

covered injectable legend drugs

Note: Needles and syringes have no

copay.

100% of approved

amount less plan

copay for the insulin

or other covered

injectable legend

drug

100% of approved

amount less plan

copay for the insulin

or other covered

injectable legend

drug

100% of approved

amount less plan

copay for the insulin or

other covered

injectable legend drug

75% of approved

amount less plan

copay for the insulin

or other covered

injectable legend drug

* BCBSM will not pay for drugs obtained from out-of-network mail order providers, including Internet providers.* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low

access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services

outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and

the provider’s charge.

Community Blue PPO LG – MAY 2014

Features of your prescription drug plan

BCBSM Custom Formulary A continually updated list of FDA-approved medications that represent each therapeutic class.

The drugs on the formulary are chosen by the BCBSM Pharmacy and Therapeutics Committee

for their effectiveness, safety, uniqueness and cost efficiency. The goal of the formulary is to

provide members with the greatest therapeutic value at the lowest possible cost.

 Tier 1 (generic) – Tier 1 includes generic drugs made with the same active ingredients,

available in the same strengths and dosage forms, and administered in the same way as

equivalent brand-name drugs. They also require the lowest copay, making them the most

cost-effective option for the treatment.

 Tier 2 (preferred brand) – Tier 2 includes brand-name drugs from the Custom Formulary.

Preferred brand name drugs are also safe and effective, but require a higher copay.

 Tier 3 (nonpreferred brand) – Tier 3 contains brand-name drugs not included in Tier 2.

These drugs may not have a proven record for safety or as high of a clinical value as Tier 1 or

Tier 2 drugs. Members pay the highest copay for these drugs.

Prior authorization/step therapy A process that requires a physician to obtain approval from BCBSM before select prescription

drugs (drugs identified by BCBSM as requiring prior authorization) will be covered. Step

Therapy, an initial step in the Prior Authorization process, applies criteria to select drugs to

determine if a less costly prescription drug may be used for the same drug therapy. Some overthe-counter

medications may be covered under step therapy guidelines. This also applies to

mail order drugs. Claims that do not meet Step Therapy criteria require prior authorization.

Details about which drugs require Prior Authorization or Step Therapy are available online at

bcbsm.com/pharmacy.

Mandatory maximum allowable cost

drugs

If your prescription is filled by an in-network pharmacy, and the pharmacist fills it with a brandname

drug for which a generic equivalent is available, you MUST pay the difference in cost

between the BCBSM approved amount for the brand-name drug dispensed and the maximum

allowable cost for the generic drug plus your applicable copay regardless of whether you or your

physician requests the brand name drug. Exception: If your physician requests and receives

authorization for a nonpreferred brand-name drug with a generic equivalent from BCBSM and

writes “Dispense as Written” or “DAW” on the prescription order, you pay only your applicable

copay.

Note: This MAC difference will not be applied toward your annual in-network deductible, nor your

annual out-of-pocket maximum.

Drug interchange and

generic copay waiver

BCBSM’s drug interchange and generic copay waiver programs encourage physicians to

prescribe a less-costly generic equivalent.

If your physician rewrites your prescription for the recommended generic or OTC alternate drug,

you will only have to pay a generic copay. In select cases BCBSM may waive the initial copay

after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver.

Quantity limits To stay consistent with FDA approved labeling for drugs, some medications may have quantity

limits.

[kumar654]

naku following things clear cheyandi brothers siters please

 

1) in network and out of net work. na employer and ee insurance vere state di and nenu inko state lo client ki pani chestunna.

2) deductables

3) co pay

4) co insurance

 

inka emina telusukovalsinavi unte meere please aa terms add chesi cheppandi

[ghazni]

deductible 5000, copay 30, coinsurance 20%

ila untey ela cover aitedo chepat..

 

deductible antey calendar year lo insurance vadu aa amount tharuvataha cover chestadu. 

 

copay is what u pay when u visit hospital for check ups..

 

coinsurance is the percent u pay after deductible..

 

simple example.. 5000 bill vachindi anuko ... 

 

so bill motam nuvey pay cheyali because deductible 5000 cover ayindi kanuka...

 

adey calendar year inko 3000 bill vastey apudu coinsurance start avtadi because deductible amount u already reached...apudu 20% of 3000 is 600.. so nuvu 600 pay cheyali...

 

so ee coinsurance enta avaraku velatadi antey ni out of pocket limit reach aye varaku... 

 

copay is usually ekuva office visits chestey aa copay plan best.........

[kumar654]

so ee plan baleda? idi base plan, inko $100 extra monthly kadithe standard plan undi andulo deductables thakkuvaga unnay.  emantaru. idi naku n wife ki so emantaru.

[kumar654]

next $100/ monthly ekkuva standard plan, following are the coverage. emantaru edi teesukovali.

 

 

Member’s responsibility (deductibles, copays, coinsurance and dollar maximums)

Deductibles $1, 500 for one member

$3,000 for the family (when two or more

members are covered under your contract)

each calendar year

Note: Deductible may be waived for

covered services performed in an innetwork

physician’s office.

$3,000 for one member

$6,000 for the family (when two or more

members are covered under your contract)

each calendar year

Note: Out-of-network deductible amounts

also count toward the in-network

deductible.

Flat-dollar copays • $20 copay for office visits and office

consultations

• $20 copay for chiropractic services and

osteopathic manipulative therapy

• $150 copay for emergency room visits

$150 copay for emergency room visits

Coinsurance amounts (percent copays)

Note: Coinsurance amounts apply once the

deductible has been met.

• 50% of approved amount for private

duty nursing care

• 10% of approved amount for mental

health care and substance abuse

treatment

• 10% of approved amount for most other

covered services (coinsurance waived

for covered services performed in an innetwork

physician’s office)

• 50% of approved amount for private

duty nursing care

• 50% of approved amount for mental

health care and substance abuse

treatment

• 50% of approved amount for most othe

[kumar654]

employer corporate insurance idi, so okavela naku $2000 bill ayindanuko anni tests ki and other stuff, a bill employer ki potada?

monthly ayihte na pay nunde cut chestadu monthly bill. 

[Puri]

less deductible + more co insurance + less out of pocket = good plan (if u think that u may need more medical attention now) 

or else nuvvu cheppina 1st plan is ohk... cheaper the better... (use cheysukonapdu) 

[kumar654]

less deductible + more co insurance + less out of pocket = good plan (if u think that u may need more medical attention now) 

or else nuvvu cheppina 1st plan is ohk... cheaper the better... (use cheysukonapdu) 

avunu bhayya, maku problems ayithe emi levu. just edina emergency ala vasthe thappa, so ma iddariki base plan with more deductible 480$ ala avutundi monthly , inko step piki ante inko $90 extra $570 ki deductables taggutunnay.  emantaru meeru, family guys suggest me please.

[zoombi]

If you are panning for kids some time soon...go for 570$ other wise go for 480$

[kumar654]

Ok. Kids plan ledu bhayya 2015 lo

[sri1]

naku following things clear cheyandi brothers siters please

 

1) in network and out of net work. na employer and ee insurance vere state di and nenu inko state lo client ki pani chestunna.

2) deductables

3) co pay

4) co insurance

 

inka emina telusukovalsinavi unte meere please aa terms add chesi cheppandi

1. Nuvvu vere state lo work chestunna it covers. BCBS website ki velte it gives a list of hospitals in their network around your zipcode. 

 

2. Deductibles ante how much you need to pay from your pocket initially. Even in BCBS PPO, HMO ani different untayi. PPO ki deductibles and HMO deductibles amount different untundi.

 

3. Copay is the money you need to pay whenever you have an office visit. Idi general ga around $30 untundi. If you visit a specialist konni plans lo $50 pay cheyyali.

 

4. Coinsurance is the money you need to pay once you reach the deductible. BCBS PPO and BCBS HMO plans ki idi different. Under BCBS PPO plan you need to pay some % of the bill. With BCBS HMO plan it's 100% covered by the insurance company. 

 

Nuvvu physician office visit chesinnapudu blood tests, ultrasounds etc same office lo cheste you don't need to pay anything. Ade bayata chepiste you need to pay from your pocket.

[kumar654]

1. Nuvvu vere state lo work chestunna it covers. BCBS website ki velte it gives a list of hospitals in their network around your zipcode. 

 

2. Deductibles ante how much you need to pay from your pocket initially. Even in BCBS PPO, HMO ani different untayi. PPO ki deductibles and HMO deductibles amount different untundi.

 

3. Copay is the money you need to pay whenever you have an office visit. Idi general ga around $30 untundi. If you visit a specialist konni plans lo $50 pay cheyyali.

 

4. Coinsurance is the money you need to pay once you reach the deductible. BCBS PPO and BCBS HMO plans ki idi different. Under BCBS PPO plan you need to pay some % of the bill. With BCBS HMO plan it's 100% covered by the insurance company. 

 

Nuvvu physician office visit chesinnapudu blood tests, ultrasounds etc same office lo cheste you don't need to pay anything. Ade bayata chepiste you need to pay from your pocket.

Thanks sri. got it.  inkokati kooda undi indulo, maximum out of packet ani oka price undi plan lo.  Deducatble amount kanna thakkubaga undi a amximum out of packet per year. what is this.

[zoombi]

Max out of pocket ante..

for example

 

if plan is 80-20

ni deductible 2000$ anuko...and max out of pocket is 3000$ an

 

niku bill 10,000$ vachindhi anuko...nuvvu max 5000$(2000(deductible )+3000(outofpocket)) kadutavu one year lo adi jan to dec e count avutundhi

[VenkatD]

Ltt

[kumar654]

Ento employer gadiki basic plan ani cheppina 2015 insurance bcbs nundi. Ippudu oka step piki velli $100 extra per month di chey ante we cant do change till next year end. Already enrollments send chesam insurance cards will be sent annaru. Nenu waste ga ekkuva deductables unnadi basic plan choose chesukunna. In network 2 members ki 10k anta and out of net work 20K deductable. Bcbs idi. Cha em cheyali