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[kumar654]

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[Osama Bin Gandhi]

ila aithe 0 deductible laga ne kada if u go to innetwork hospitals..aa may be kosam oka sari bcbs call chesi clauses kanukko..

 

Hi, naku ee deductibles gurinchi teliyadu. can you please evarina cheppara. manam year lo $3000 worth medical tests avi cheyinchukunnam anuko ee deductibles ela work chestay. following is the base plan nenu theesukuntunna next year from employer and bcbs. idi naku n na spouse ki, koncham cheppara. vere standard plan lo deductibles thakkuvaga unnay. 

 

 

 

following are in network & out of network rates in this plan BCBS PPO base plan

 

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

 

 

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.

 

 

[Puri]

gp