Group PPO EverydayHealth Silver 2500 Plan Attachment

Group PPO EverydayHealth Silver 2500 Plan Attachment

Statewide Network – Off Exchange

azblue.com

GRP PPO EDH PA 01/20 22303 0120 ACA SIL 2500 STA OFF

http://azblue.com

PLAN NETWORK

Know your provider’s network and eligibility status before you receive services. Your Plan Network is the Statewide N etwork. The Blue Cross Blue Shield of Arizona (BCBSAZ) Provider directory of Statewide network Providers is available online at www.azblue.com. If you do not have Internet access, would like to request a paper copy of the directory, or you have questions about a provider’s network participation, please call BCBSAZ Customer Service at the number on your ID card before you receive services.

GRP PPO EDH PA 01/20 2 ACA SIL 2500 STA OFF

http://www.azblue.com

MEMBER COST SHARING & OTHER PAYMENTS

Members pay part of the costs for benefits received under this plan. Depending on your particular Benefit Plan, the Service you receive and the Provider you choose, you may have an Access Fee, Balance Bill, Coinsurance, Copay, deductible, or some combination of these payments. Each Cost Share and other payment type is explained below. This section, the “Cost-Share Table” section that follows, and your SBC will explain which Cost-share types and other payments apply to each benefit. BCBSAZ uses your claims to track whether you have met some Cost-share obligations. We apply claims based on the order in which we process the claims and not based on date of Service.

Access Fee

An Access Fee is a fixed fee you pay to a Provider for certain Covered Services, usually at the time of Service. If an Access Fee applies to a particular Service, you must pay the Access Fee plus any other applicable Cost Share for the Service. Access fees do not count toward meeting your Calendar-year Deductible.

Balance Bill

The Balance Bill refers to the amount you may be charged for the difference between a noncontracted provider’s Billed Charges and the Allowed Amount. Any amounts paid for balance bills do not count toward deductible, Coinsurance, or the Out-of-pocket Maximum.

Noncontracted Providers have no obligation to accept the Allowed Amount. You are responsible to pay a noncontracted provider’s Billed Charges, even though BCBSAZ will reimburse your claims based on the Allowed Amount. Depending on what billing arrangements you make with a noncontracted Provider, the Provider may charge you for full Billed Charges at the time of Service or seek to Balance Bill you for the difference between Billed Charges and the amount that BCBSAZ reimburses you on a claim.

Benefit Maximums

Some benefits may have a specific benefit maximum or limit based on the number of days or visits, type, timeframe (calendar year or Benefit Plan), age, gender, or other factors. If you reach a benefit maximum, any further services are not covered under that benefit and you may have to pay the provider’s Billed Charges for those services. However, if you reach the benefit maximum on a particular line of a claim, you will be responsible for paying only up to the Allowed Amount for the remaining charges on that line of the claim. All Benefit Maximums are included in the applicable benefit description.

Calendar-Year Deductible (Individual and Family)

A Calendar-year Deductible is the amount each Member must pay for Covered Services each January through December before the Benefit Plan begins to pay for Covered Services. The deductible applies to every covered Service unless the specific benefit section says it does not apply. The deductible is calculated based on the Allowed Amount. Amounts you pay for copays and access fees do not count toward the deductible.

If you have family coverage, there is also a Calendar-year Deductible for the family. Amounts counting toward an individual’s Calendar-year Deductible will also count toward any family deductible. When the family satisfies its Calendar-year Deductible, it also satisfies the deductible for all the individual members. An individual Member cannot contribute more than his or her individual deductible toward the family’s deductible.

Coinsurance

Coinsurance is a percentage of the Allowed Amount that you pay for certain Covered Services after meeting any applicable deductible. BCBSAZ subtracts any applicable access fees and Precertification Charges from the Allowed Amount before calculating Coinsurance. Coinsurance applies to every covered Service unless the specific benefit section says it does not apply. In most cases, your Coinsurance percentage is higher when you use an out-of-network Provider.

BCBSAZ normally calculates Coinsurance based on the Allowed Amount. There is one exception. If a hospital provider’s Billed Charges are less than the hospital’s reimbursement, BCBSAZ will calculate your Coinsurance based on the lesser billed charge.


Copay

A Copay is a specific dollar amount you must pay to the Provider for some Covered Services. If a Copay applies to a covered Service, you must pay it when you receive services. Different services may have different Copay amounts and are shown in the “Cost-Share Table” section that follows and on your SBC. Usually, if a Copay does not apply, you will pay applicable deductible and Coinsurance.

Out-of-Pocket Maximum (Individual & Family)

An Out-of-pocket Maximum is the amount each Member must pay each year before the plan begins paying 100 percent of the Allowed Amount on Covered Services, for the remainder of the calendar year. The payments listed below do not count toward the Out-of-pocket Maximum. You must keep paying them even after you reach your Out-of-pocket Maximum: • Amounts above a benefit maximum • Any amounts for balance billing • Any amounts for noncovered services • Any charges for lack of Precertification

If you have family coverage, there is an Out-of-pocket Maximum for your family. Amounts applied to each member’s Out-of-pocket Maximum also apply to the family Out-of-pocket Maximum. The family maximum is applied in the same way as the individual maximum described above and is subject to the same rules. When the family has met its family Out-of-pocket Maximum, it also satisfies the Out-of-pocket Maximum requirements for all the individual members.

Pediatric Dental Services

Least Expensive Available Treatment (LEAT) Processing for Pediatric Dental Services

Coverage for Restorative (Type II and III) Services is subject to LEAT processing. BCBSAZ determines whether a restorative service is subject to LEAT processing based upon its LEAT Guidelines, which are available to you upon request. If a restorative service is subject to LEAT processing, the LEAT for the restorative service is a covered Service under this Benefit Plan (the “Covered Restorative Service”). The more expensive available restorative treatment is not a covered Service under this Benefit Plan (the “Non-Covered Restorative Service”).

Your Cost Share is based upon the Allowed Amount for the Covered Restorative Service. The difference between the Allowed Amount for the Covered Restorative Service and the dentist’s Billed Charges for the Non-Covered Restorative Service is the “LEAT Balance Bill.” If LEAT processing applies and you choose the Non-Covered Restorative Service, you will pay both the Cost Share for the Covered Restorative Service and the LEAT Balance Bill. This is true even if you receive the Non-Covered Restorative Service from an in-network Dentist. The LEAT Balance Bill does not count toward deductible or the Out-of-pocket Maximum.

Predetermination of Benefits for Pediatric Dental Services

Your Dentist may ask BCBSAZ or its contracted vendor to estimate the benefits that will be available to cover a proposed treatment plan. Upon request, BCBSAZ or its contracted vendor will send a predetermination of benefits to your Dentist. Because BCBSAZ or its contracted vendor will require detailed information, including the procedure codes for your proposed treatment, BCBSAZ or its contracted vendor will accept predetermination requests only from Dentists. BCBSAZ or its contracted vendor will provide a non-binding estimate of your benefits that would be available under your plan, based on the information available to us at the time the request is submitted. Your claim may process differently from the predetermination of benefits for reasons that include, but are not limited to, whether BCBSAZ or its contracted vendor processes additional claims after the predetermination is issued, whether there are any changes to your eligibility status between the date of the predetermination of benefits and the date of Service, whether your Dentist submits a claim with different procedures or codes than were submitted with the predetermination request, and whether “Coordination of Benefits” applies.

You may want to ask your Dentist to submit a predetermination request if you are considering an extensive course of treatment. If LEAT analysis would apply to your proposed treatment, the predetermination will provide an estimate of your Cost Share based on the LEAT. You will be responsible for any Balance Bill. However, BCBSAZ or its contracted vendor does not require predeterminations for any services covered under this plan. Predeterminations are not the same as precertifications, which are required prior to receipt of certain covered medical services. Your Dentist may call BCBSAZ or its contracted vendor at the Customer Service number on your ID card for information on how to request a predetermination of benefits. GRP PPO EDH PA 01/20 4 ACA SIL 2500 STA OFF

Pharmacy Deductible (Individual)

A Pharmacy Deductible is the amount each Member must pay for level 2 and level 3 medications covered under the “Pharmacy Benefit” each January through December before the Benefit Plan begins to pay for those medications. After meeting the Pharmacy Deductible, you pay copays for level 2 and level 3 medications. The Pharmacy Deductible is calculated on the medication Allowed Amount.

Precertification Charges

If your out-of-network Provider does not obtain Precertification from BCBSAZ for a Service that requires it, you are subject to a precertification charge or complete loss of benefit as shown on your SBC. Amounts applied as Precertification Charges do not count toward the Calendar-year Deductible or Out-of-pocket Maximum.


COST-SHARE TABLE

Description In-Network Cost Share Out-of-Network Cost Share

CALENDAR-YEAR DEDUCTIBLE $2,500 per Member $5,000 per family

$3,000 per Member $6,000 per family

OUT-OF-POCKET MAXIMUM $7,400 per Member $14,800 per family

$14,800 per Member $29,600 per family

Benefit In-Network Cost Share Out-of-Network Cost Share

AMBULANCE SERVICES Deductible is waived. You pay 20% Coinsurance.

BEHAVIORAL AND MENTAL HEALTH SERVICES (Inpatient Facility and Professional Services)

You pay in-network deductible up to $2,500 and 20% in-network Coinsurance.

You pay out-of-network deductible up to $3,000 and 50% out-of-network Coinsurance. You also pay the Balance Bill for services from noncontracted Providers.

BEHAVIORAL AND MENTAL HEALTH SERVICES (Outpatient Facility and Professional Services)

You pay 1 Copay per Member, per Provider, per day for services provided during an of fice, home, or walk-in clinic visit. Your Copay varies depending on whether you see a PCP ($40) or a Specialist ($85). You pay in-network deductible up to $2,500 and 20% in-network Coinsurance for services in other locations.


BEHAVIORAL THERAPY SERVICES FOR THE TREATMENT OF AUTISM SPECTRUM DISORDER

You pay 1 Copay per Member, per Provider, per day for services provided during an office, home, or walk-in clinic visit. Your Copay varies depending on whether you see a PCP ($40) or a Specialist ($85). You pay in-network deductible up to $2,500 and 20% in-network Coinsurance for services in other locations.


CATARACT SURGERY AND KERATOCONUS

You pay in-network deductible up to $2,500 and 20% in-network Coinsurance for professional services provided in a facility and for inpatient and outpatient facility charges. For Physician office visits, you pay a PCP Copay ($40) or a Specialist Copay ($85).


CHIROPRACTIC SERVICES You pay a Specialist Copay ($85) per Member, per Provider, per day for services provided during an office, home, or walk-in clinic visit. The Copay does not apply if you receive only physical medicine and Rehabilitative Services and no other covered Service during your visit. You pay in-network deductible up to $2,500 and 20% in-network Coinsurance for physical medicine and Rehabilitative Services and for Chiropractic Services in other locations.


CHRONIC DISEASE EDUCATION AND TRAINING (Including Nutritional Counseling and Training)

Your Cost Share is waived. You pay out-of-network deductible up to $3,000 and 50% out-of-network Coinsurance. You also pay the Balance Bill for services from noncontracted Providers.

CLINICAL TRIALS You pay in-network deductible up to $2,500 and 20% in-network Coinsurance for professional services provided in a facility and for inpatient and outpatient facility charges. For Physician office visits, you



Benefit In-Network Cost Share Out-of-Network Cost Share pay a PCP Copay ($40) or a Specialist Copay ($85).

DENTAL SERVICES – MEDICAL



DURABLE MEDICAL EQUIPMENT (DME), MEDICAL SUPPLIES, AND PROSTHETIC APPLIANCES AND ORTHOTICS

For Physician office visits, you pay a PCP Copay ($40) or a Specialist Copay ($85). When DME is picked up in the physician’s office but billed through a DME supplier, you pay in-network deductible up to $2,500 and 20% in-network Coinsurance. If you have a Physician office visit at the time you pick up your DME, Medical Supplies, or Prosthetic Appliances or Orthotics, you also pay a PCP Copay or a Specialist Copay. You pay in-network deductible up to $2,500 and 20% in-network Coinsurance for services received outside a physician’s office. Your Cost Share i s waived for one FDA-approved manual or electric breast pump and breast pump supplies per Member, per calendar year.


EMERGENCY SERVICES You pay your in-network Cost Share for Emergency Services, even for services from out-of-network Providers. You pay in-network deductible up to $2,500 and 20% in-network Coinsurance.

If you receive Emergency Services from a noncontracted facility or professional Provider, BCBSAZ will base the Allowed Amount used to calculate your Cost Share on the highest of the three following amounts, not to exceed the applicable provider’s Billed Charges: • The median in-network Provider negotiated rate for the emergency service

furnished, • The amount for the emergency service calculated using the same method

BCBSAZ generally uses to determine reimbursement for non-emergency out-ofnetwork services, or

• The amount that would be paid by Medicare Part A or B.

For all non-emergency services following the emergency treatment and stabilization, the Cost Share w ill depend on the provider’s network status and the place you receive services.

The provider’s Billed Charges often exceed the above amounts, which leaves a Balance Bill. You will be responsible for the Balance Bill, which may be substantial.

EOSINOPHILIC GASTROINTESTINAL DISORDER

Deductible is waived. You pay 20% for the Cost of Formula.

Deductible is waived. You pay 25% for the Cost of Formula.

“Cost” is defined as either Billed Charges, if the Formula is purchased from an outof-network Provider, or the Allowed Amount, if purchased from an in-network Provider.

FAMILY PLANNING (CONTRACEPTIVES AND STERILIZATION)

Implanted Devices: Your Cost Share is waived for professional charges for implantation and/or removal (including follow-up care) of FDA-approved implanted contraceptive devices when the purpose of the procedure is contraception, as documented by your Provider on the claim.

Sterilization Procedures: Your Cost Share is waived for professional and facility charges for FDA-approved female sterilization procedures when the purpose of the procedure is contraception, as documented by your Provider on the claim. You pay deductible up to $2,500 and 20%



Benefit In-Network Cost Share Out-of-Network Cost Share in-network Coinsurance for FDA-approved male sterilization procedures.

Hormonal Contraceptive Methods: Your Cost Share is waived for oral contraceptives, patches, rings, and contraceptive injections.

Emergency Contraception: Your Cost Share is waived for FDA-approved overthe-counter emergency contraception when prescribed by a Physician or other Provider.

Barrier Contraceptive Methods: Your Cost Share is waived for diaphragms, cervical caps, cervical shields, female condoms, sponges, and spermicides.

HEARING SERVICES You pay in-network deductible up to $2,500 and 20% in-network Coinsurance for professional services provided in a facility, for inpatient and outpatient facility charges, and for hearing devices obtained in any location. For Physician office visits, you pay a PCP Copay ($40) or a Specialist Copay ($85).


HOME HEALTH SERVICES You pay in-network deductible up to $2,500 and 20% in-network Coinsurance.


If you believe you have paid more for a self-administered version of a Cancer Treatment Medication than for an injected or intravenously administered version of a Cancer Treatment Medication, please call the Pharmacy Benefit Customer Service number on your ID card.

HOSPICE SERVICES Your Cost Share i s waived. Your Cost Share is waived. You pay the Balance Bill for services from noncontracted Providers.

INPATIENT AND OUTPATIENT DETOXIFICATION

You pay a Physician PCP Copay ($40) or a Specialist Copay ($85) for services in a physician’s office or walk-in clinic. You pay in-network deductible up to $2,500 and 20% in-network Coinsurance f or services in other locations.


INPATIENT HOSPITAL You pay in-network deductible up to $2,500 and 20% in-network Coinsurance. Your Cost Share is waived f or facility charges for FDA-approved female sterilization procedures when the purpose of the procedure is contraception, as documented by your Provider on the claim.


You pay a $1,000 Bariatric Surgery Access Fee for all bariatric surgeries, in addition to deductible and Coinsurance. The Bariatric Surgery Access Fee applies toward the professional charges for Bariatric Surgery.

INPATIENT REHABILITATION SERVICES – EXTENDED ACTIVE REHABILITATION (EAR) AND SKILLED NURSING FACILITY (SNF) SERVICES





LONG-TERM ACUTE CARE (INPATIENT)



MATERNITY

“Global Charge” is a fee charged by the delivering Provider that includes certain prenatal, delivery, and postnatal services.

Inpatient Services: You pay in-network deductible up to $2,500 and 20% in-network Coinsurance.

Outpatient Services: You pay 1 PCP Copay ($40) or 1 Specialist Copay ($85) for your first prenatal office or home visit, which covers all Physician Services included in the physician’s Global Charge. You pay 1 Copay, per Member, per Provider, per day for other Physician office or home visits not included in the Global Charge. You pay deductible up to $2,500 and 20% in-network Coinsurance for professional services in an outpatient facility and for outpatient facility charges.


Your Cost-share obligations may be affected by the addition of a newborn or adopted child, as described in the “Plan Administration” section of the Base Benefit Book. If you have coverage only for yourself and no Dependents, addition of a child will result in a change from individual coverage to family coverage. If you currently have a per person deductible and Out-of-pocket Maximum, when a child is added to your Plan, you will also be required to meet a family deductible and Out-of-pocket Maximum, and you may be required to pay additional premium.

MEDICAL FOODS FOR INHERITED METABOLIC DISORDERS

Deductible is waived. You pay 20% for the Cost of Medical Foods.

Deductible is waived. You pay 50% for the Cost of Medical Foods.

“Cost” is defined as either Billed Charges, if the Member buys the Medical Foods from an out-of-network Provider or the Allowed Amount, if the Member buys the Medical Foods from an in-network Provider.

NEUROPSYCHOLOGICAL AND COGNITIVE TESTING



OUTPATIENT SERVICES Diagnostic Laboratory Services: You pay a PCP Copay ($40) or a Specialist Copay ($85) for services in a physician’s office (Copay is waived if you receive only covered laboratory services during your visit), except professional services provided by a pathologist or dermapathologist will be subject to in-network deductible up to $2,500 and 20% in-network Coinsurance. You pay in-network deductible up to $2,500 and 20% in-network Coinsurance for services in other locations.

Radiology Services: You pay a PCP Copay ($40) or a Specialist Copay ($85) for services in a physician’s office, except professional services provided by a radiologist will be subject to in-network deductible up to $2,500 and 20% in-network Coinsurance. You pay in-network deductible up to $2,500 and 20% in-network Coinsurance for services in other locations.



Benefit In-Network Cost Share Out-of-Network Cost Share Outpatient Facility Services (Including Outpatient Surgery): in-network deductible up to $2,500 and 20% in-network Coinsurance. Your Cost Share is waived for facility charges for FDA-approved female sterilization procedures when the purpose of the procedure is contraception, as documented by your Provider on the claim.

Sleep Studies: You pay in-network deductible up to $2,500 and 20% in-network Coinsurance.

Medications Administered in an Outpatient Facility: You pay in-network deductible up to $2,500 and 20% in-network Coinsurance.

You pay a $1,000 Bariatric Surgery Access Fee for all bariatric surgeries, in addition to deductible and Coinsurance. The B ariatric Surgery Access Fee applies toward the professional charges for Bariatric Surgery.

PHARMACY BENEFIT

If you are currently obtaining a covered specialty medication from a Specialty Pharmacy, you can receive that medication from a network retail pharmacy. Please call the Pharmacy Benefit Customer Service number on your ID card if you need assistance with this issue.

If you are currently obtaining a covered medication from the network mail order pharmacy, you have the option to receive that medication from a network retail pharmacy. Please call Pharmacy Benefit Customer Service at the number on your ID card if you need assistance with this issue.

If you believe you have paid more for a self-administered version of a Cancer Treatment Medication than for an injected or intravenously administered version of a Cancer Treatment Medication, please call the Pharmacy Benefit Customer Service number on your ID card.

If you are taking two or more prescription medications for a chronic condition, you may request early or short refills of eligible covered medications by calling the Pharmacy Benefit Customer Service number on your ID card and requesting enrollment in the BCBSAZ Medication Synchronization program. If you are enrolled in the BCBSAZ Medication Synchronization program, your

Retail/Mail Order Pharmacy Medications: • Level 1, 30-day supply: You pay a $35

Copay. • Level 2, 30-day supply: You pay the

Pharmacy Deductible up to $350 per Member, then you pay a $100 Copay.

• Level 3, 30-day supply: You pay the Pharmacy Deductible up to $350 per member, then you pay a $200 Copay. You pay the level 3 Cost Share for medications that are Formulary Exceptions, including Compounded Medications.

You may obtain up to a 90-day supply of covered medications. Not all medications are available for more than a 30- or 60-day supply. Your Cost Share will vary depending on the type of pharmacy, the quantity, and level of the medication: • Level 1, in-network retail or mail order

pharmacy, 31- to 60-day supply: You pay two times the level 1 Copay for a 30-day supply. • Level 1, in-network mail order

pharmacy, 61- to 90-day supply: You pay two times the level 1 Copay for a 30-day supply. • Level 1, in-network retail pharmacy, 61-

to 90-day supply: You pay three times the level 1 Copay for a 30-day supply. • Levels 2 & 3, in-network retail or mail

order pharmacy, 31- to 60-day supply: You pay the Pharmacy Deductible then two times the applicable Copay for a 30day supply. • Levels 2 & 3, in-network mail order

pharmacy, 61- to 90-day supply: You pay the Pharmacy Deductible then two times the applicable Copay for a 30-day supply. • Levels 2 & 3, in-network retail

pharmacy, 61- to 90-day supply: You pay the Pharmacy Deductible then three times the applicable Copay for a 30-day supply.

You pay your in-network Cost-share amount plus the Balance Bill.

The following are not covered when obtained from out-of-network pharmacies: • 90-day supply at retail • Mail order medications • Specialty medications


Benefit In-Network Cost Share Out-of-Network Cost Share Cost Share for eligible covered medications will be adjusted for any early or short refills of those medications.

Your Cost Share is based on the level to which BCBSAZ has assigned the medication at the time the prescription is filled. No exceptions will be made regarding the assigned level of a medication. BCBSAZ may change the level of a medication at any time without notice. Go to www.azblue.com to view the lists of prescription drug tiers. To confirm the level of a particular medication, you may also call Pharmacy Benefit Customer Service at the number on your ID card.

If you purchase a brand-name medication when a generic equivalent is available, you will pay the level 1 Copay plus the difference between the Allowed Amount for the generic and the brand-name medication, even if the prescribing Provider indicates on the prescription that the brand-name medication should be dispensed. If you have completed Step Therapy and are taking a brand-name medication with a generic equivalent as a result of the Step Therapy process, you pay the Cost Share applicable to the brand-name medication (after meeting the Pharmacy Deductible for levels 2 and 3 medications).

Other than as noted in this section, no exceptions will be made concerning the Cost Share you will pay, regardless of the medical reasons requiring use of a particular medication, even when there is no equivalent medication on a lower level or if you are unable to take a medication on the lower level for any reason.

Your Cost Share is waived for preventive medications and for covered vaccines. BCBSAZ will determine which medications are considered preventive and for which your Cost Share is waived. BCBSAZ also determines which vaccines are covered and for which your Cost Share is waived.

For certain covered preventive medications and items, your Cost Share is waived for the generic version of the medication or item and you pay applicable Cost Share for the brand-name version of the medication or item. You may request an exception for waiver of Cost Share for the brand-name version of a preventive medication or item.

Your Cost Share is waived for the following contraceptive methods when prescribed by your Provider and obtained from an in-network pharmacy: • FDA-approved diaphragms, cervical

caps, and cervical shields • FDA-approved emergency

contraception for members of any age • FDA-approved generic oral, patch,

vaginal ring, and injectable contraceptives




• FDA-approved brand oral, patch, vaginal ring, and injectable contraceptives with no generic equivalent components

• Female condoms • Sponges and spermicides

See the “Guidance Regarding Preventive Medications” section on www.azblue.com for a list of contraceptive methods covered as Preventive Services under this benefit. Contraceptives must be prescribed for or include the purpose of contraception and not be prescribed solely for some other medical reason to be covered with no Member Cost Share.

Specialty Medications Obtained from Specialty Pharmacies: In-network medical and Pharmacy deductibles are waived. You pay 50% specialty medication Coinsurance. For cancer treatment medications that are also classified as Specialty Medications, you pay the level 1 pharmacy Copay. BCBSAZ determines which cancer treatment medications are classified as Specialty Medications. For certain cancer treatment medications, as determined by BCBSAZ, you will receive a 15-day supply, and pay one-half of the level 1 pharmacy Copay the first time you receive the medication. You will be able to refill the medication every 15 days, and you will continue to pay one-half of the level 1 Copay for each refill during your first three months of treatment with the medication. If you experience side effects from the medication during the three-month period, your prescribing Provider may change your medication. If you tolerate the medication, you will be able to refill the Cancer Treatment Medication for up to 30 days after three months of treatment.

PHYSICAL THERAPY (PT) – OCCUPATIONAL THERAPY (OT) – SPEECH THERAPY (ST) – COGNITIVE THERAPY (CT) – CARDIAC AND PULMONARY HABILITATIVE SERVICES



PHYSICAL THERAPY (PT) – OCCUPATIONAL THERAPY (OT) – SPEECH THERAPY (ST) – COGNITIVE THERAPY (CT) – CARDIAC AND PULMONARY REHABILITATIVE SERVICES



PHYSICIAN SERVICES

If you receive Preventive Services from an in-network Physician, your Cost Share may be waived.

You pay 1 Copay per Member, per Provider, per day for services provided during an office, home, or walk-in clinic visit. Your Copay varies depending on whether you see a PCP ($40) or Specialist ($85).




Benefit In-Network Cost Share Out-of-Network Cost Share Your Copay is waived if you only receive the following services and no other covered Service during your home or office visit: • Covered allergy injections • Covered immunizations • Covered laboratory services • Covered PT, OT, ST; these services

are subject to in-network deductible up to $2,500 and 20% in-network Coinsurance

You pay in-network deductible up to $2,500 and 20% in-network Coinsurance for services in other locations.

Your Cost Share will be waived for the following services when the purpose of the procedure is contraception, as documented by your Provider on the claim: • Professional Physician Services for

FDA-approved female sterilization procedures, regardless of the location of Service.

• Professional Physician Services for fitting, implantation, and/or removal (including follow-up care) of FDA-approved female contraceptive devices provided during a Physician office, home, or walk-in clinic visit.

• FDA-approved implanted contraceptive devices.

• The following FDA-approved generic and brand with no generic equivalent prescription hormonal and barrier contraceptive methods and devices: patches, rings, contraceptive injections, diaphragms, cervical caps, cervical shields, female condoms, sponges, and spermicides. See the “Guidance Regarding Preventive Medications” section on www.azblue.com for a list of contraceptive methods covered as Preventive Services under the “Pharmacy Benefit.”

You pay in-network deductible up to $2,500 and 20% in-network Coinsurance for professional services provided by a radiologist or pathologist, including a dermapathologist, and for professional services related to a sleep study even when the services are provided in a physician’s office. You pay in-network deductible up to $2,500 and 20% in-network Coinsurance for medications administered in a physician’s office.

POST-MASTECTOMY SERVICES

You pay in-network deductible up to $2,500 and 20% in-network Coinsurance for professional services provided in a facility and for inpatient and outpatient facility charges. For Physician office visits, you pay a PCP Copay ($40) or Specialist Copay ($85).

You pay out-of-network deductible up to $3,000 and 50% out-of-network Coinsurance. You also pay the Balance Bill for services from noncontracted providers.

PRESCRIPTION MEDICATIONS FOR THE TREATMENT OF CANCER

See the “Pharmacy Benefit” row to determine your Cost Share for services received through the “Pharmacy Benefit.” You pay in-network deductible up to $2,500

You pay out-of-network deductible up to $3,000 and 50% out-of-network Coinsurance. You also pay the



Benefit In-Network Cost Share Out-of-Network Cost Share and 20% in-network Coinsurance for medications received through your medical benefits.

Balance Bill for services from noncontracted Providers.

PREVENTIVE SERVICES

You pay applicable Cost Share for any tests, procedures, or services not covered in the “Preventive Services” section of the Base Benefit Book.

Your Cost Share is waived, regardless of the location where services are provided, if: • You receive one of the services covered

in the “Benefit Description” subsection of the “Preventive Services” section in the Base Benefit Book;

• The procedure code, the diagnosis code, or the combination of procedure codes and diagnosis codes billed by your Provider on the line of the claim indicates the Service is preventive; and

• The primary purpose of the visit at which services were rendered was for preventive care.

For certain covered preventive medications and items, your Cost Share is waived for the generic version of the medication or item and you pay applicable Cost Share for the brand-name version of the medication or item. You may request an exception for waiver of Cost Share for the brand-name version of a preventive medication or item. See the “Benefit Description” subsection under “Preventive Services” in the Base Benefit Book.


RECONSTRUCTIVE SURGERY AND SERVICES



SERVICES TO DIAGNOSE INFERTILITY



TELEHEALTH SERVICES Your Cost Share is waived for telehealth medical. You pay a telehealth counseling Copay ($20) for services provided by a counselor, or a telehealth psychiatry Copay ($45) for services provided by a psychiatrist.

Not covered.

TELEMEDICINE SERVICES You pay the Cost-share amounts applicable to the services provided via telemedicine. Cost Share applies for the Service provided at your physical location, and also for the Service rendered remotely by the telemedicine Provider. To illustrate: if you are in a PCP’s office and receive a consultation from a remote Specialist, you pay the Cost Share applicable for a PCP office visit and the Cost Share applicable for a Specialist office visit or consultation. If you are at home and receive a consultation from a remote Specialist, you pay only the Specialist Cost Share because no other Provider is involved at your location.

Not covered, except for Emergency Services and Urgent Care. You pay the Cost-share amounts applicable to all services provided via telemedicine. You will always pay in-network Cost Share for Emergency Services provided via telemedicine.



TRANSPLANTS – ORGAN – TISSUE – BONE MARROW TRANSPLANTS AND STEM CELL PROCEDURES If both a donor and a transplant recipient are covered by a BCBSAZ plan or a plan administered by BCBSAZ, the transplant recipient pays the Cost Share related to the transplant.


You pay out-of-network deductible up to $3,000 and 50% out-of-network Coinsurance. You also pay the Balance Bill for services from noncontracted Providers. Certain facilities are contracted with the Plan Network to provide covered transplants to BCBSAZ members. Not all such facilities are contracted to provide services related to a covered transplant, such as pre-transplant testing, certain types of chemotherapy and radiation therapy and other services covered under this plan. If you receive pre-transplant testing or other services associated with the transplant from a facility that is not contracted with the Plan Network or a Host Blue plan, or is not a Blue Distinction Center for Transplants to provide those services, you will pay the Balance Bill plus out-of-network Cost Share.

TRANSPLANT AND GENE THERAPY TRAVEL AND LODGING

Your Cost Share is waived. Maximum of $10,000 reimbursement per Member, per transplant or gene therapy

treatment.

URGENT CARE You pay an Urgent Care Copay ($85) per Member, per Provider, per day for services received from a Provider who is contracted with the Plan Network to render Urgent Care services. If you receive services from a Plan Network Provider who is not specifically contracted for Urgent Care services, you pay a PCP Copay ($40) or Specialist Copay ($85) for services in a physician’s office, home visit, or walk-in clinic. You pay deductible up to $2,500 and 20% Coinsurance for services in all other locations.


PEDIATRIC DENTAL TYPE I SERVICES

Your Cost Share is waived. Your Cost Share is waived. You pay the Balance Bill.

PEDIATRIC DENTAL TYPE II SERVICES

You pay in-network deductible up to $2,500 and 50% Coinsurance. All claims for Type II services are subject to analysis for the LEAT processing. If you choose a Non-Covered Restorative Service, you pay your Cost Share plus the LEAT Balance Bill.

You pay out-of-network deductible up to $3,000 and 60% Coinsurance, plus the Balance Bill. All claims for Type II services are subject to analysis for the LEAT processing. If you choose a Non-Covered Restorative Service, you pay your Cost Share and the Balance Bill, plus the LEAT Balance Bill.

PEDIATRIC DENTAL TYPE III SERVICES

You pay in-network deductible up to $2,500 and 50% Coinsurance. All claims for Type III services are subject to analysis for the LEAT processing. If you choose a Non-Covered Restorative Service, you pay your Cost Share plus the LEAT Balance Bill.

You pay out-of-network deductible up to $3,000 and 60% Coinsurance, plus the Balance Bill. All claims for Type III services are subject to analysis for the LEAT processing. If you choose a Non-Covered Restorative Service, you pay your Cost Share and the Balance Bill, plus the LEAT Balance Bill.

PEDIATRIC DENTAL TYPE IV SERVICES

You pay in-network deductible up to $2,500 and 50% Coinsurance.

You pay out-of-network deductible up to $3,000 and 60% Coinsurance, plus the Balance Bill.



PEDIATRIC VISION EXAMS (ROUTINE)

For Members Under Age 5: Your Cost Share is waived.

For Members Age 5-19: You pay a ($40) pediatric Routine Vision Exam Copay.


If a medical condition is identified during your Routine Vision Exam, you will be responsible for additional cost sharing.

PEDIATRIC CONTACT LENS FIT AND FOLLOW UP

Your Cost Share is waived. Not covered.

PEDIATRIC EYEWEAR Your Cost Share is waived. Not covered.

PEDIATRIC LOW VISION EVALUATION AND FOLLOW UP

Your Cost Share is waived. You pay out-of-network deductible up to $3,000 and 50% out-of-network Coinsurance. You also pay the Balance Bill for services from noncontracted Providers.

PEDIATRIC LOW VISION HARDWARE

Your Cost Share is waived. Not covered.

NONDISCRIMINATION STATEMENT

BCBSAZ complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call (602) 864-4884 for Spanish and (877) 475-4799 for all other languages and other aids and services.

If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: BCBSAZ’s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ 85002-3466, (602) 864-2288, TTY/TDD (602) 864-4823, [email protected]. You can file a grievance in person or by mail or email. If you need help filing a grievance, BCBSAZ’s Civil Rights Coordinator is available to help you. You also can file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue S.W., Room 509F, HHH Building, Washington, D.C. 20201, (800) 3681019, TDD (800) 537-7697. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.


mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

MULTI-LANGUAGE INTERPRETER SERVICES


Documents

Group PPO EverydayHealth Silver 2500 Plan Attachment