2013 Benefit Enrollment Guide - Troy University

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Are there services this plan doesn’t cover Yes. Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services. • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use In-Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider’s office or clinic Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/screening/immunization Your cost if you use an In Network Provider 0% coinsurance & $25 copay 0% coinsurance & $40 copay 20% coinsurance for chiropractor 0% coinsurance & $25 copay Your cost if you use an Out of Network Provider 20% coinsurance 20% coinsurance 20% coinsurance for chiropractor Not Covered Limitations & Exceptions Subject to overall deductible for out of network Subject to overall deductible for out of network Subject to overall deductible; limited to a maximum of 12 visits or a $400 maximum payment per member per calendar year; in Alabama, out of network coinsurance is 50% Facility copay may apply; age and visit limitations will apply Diagnostic test (x-ray, blood work) No Charge 20% coinsurance If you have a test Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance Subject to overall deductible for out of network Subject to overall deductible for out of network; precertification may be required for coverage 2 of 7
Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at bcbsal.com/pharmacy. If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Your cost if you use an In Network Provider 0% coinsurance & $10 copay 0% coinsurance & $35 copay 0% coinsurance & $50 copay 0% coinsurance & $50 copay 0% coinsurance & $125 copay Your cost if you use an Out of Network Provider Not Covered Not Covered Not Covered Not Covered 20% coinsurance Physician/surgeon fees No Charge 20% coinsurance Emergency room services No Charge No Charge Limitations & Exceptions Prior authorization for specific drugs required for coverage; mail order is available Prior authorization for specific drugs required for coverage; mail order is available Prior authorization for specific drugs required for coverage; mail order is available Specialty drugs subject to preferred brand or non-preferred brand copay; prior authorization for specific drugs required for coverage; mail order is available Subject to overall deductible for out of network; in Alabama, out of network not covered Subject to overall deductible for out of network <strong>Benefit</strong>s listed are emergency room services for the treatment of accidental injury; physician copay may apply; other medical emergencies have higher patient responsibility Emergency medical transportation 20% coinsurance 20% coinsurance Subject to overall deductible Urgent care Facility fee (e.g., hospital room) 0% coinsurance & $40 copay 0% coinsurance & $300 per admission 20% coinsurance 20% coinsurance Physician/surgeon fee No Charge 20% coinsurance Subject to overall deductible for out of network; specialist copay may apply Subject to per admission deductible; precertification is required for coverage; in Alabama, out of network not covered Subject to overall deductible for out of network 3 of 7
Page 1 and 2: 2013 Benefit Enrollment Guide an ov
Page 3 and 4: introduction Enrollment Current Emp
Page 5 and 6: Healthcare Benefits Medical (Blue C
Page 7 and 8: Healthcare Benefits Pre-Tax Cafeter
Page 9 and 10: Healthcare Benefits BlueCard Worldw
Page 11 and 12: Voluntary Life Insurance Voluntary
Page 13 and 14: travel assistance MEDEX ® Travel A
Page 15 and 16: flexible spending Flexible Spending
Page 17 and 18: etirement Mandatory Retirement Plan
Page 19 and 20: important notices Summary Plan Desc
Page 21: Troy University-54395/000 Coverage
Page 25 and 26: Excluded Services & Other Covered S
Page 27 and 28: Questions and answers about the Cov
Page 29 and 30: BlueCard PPO: Troy University Cover

2013 Benefit Enrollment Guide - Troy University

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