2013 Benefit Enrollment Guide - Troy University

Healthcare Benefits
Medical (Blue Cross Blue Shield of AL)
Medical Summary of Benefits
PPO Plan Benefits In-Network Out-of-Network Out-of-Area
Office Visits $25 PCP / $40 Specialist 70% after deductible 80% after deductible
Hospital Services
Inpatient
Outpatient Surgery &
Emergency Service
Preventive Care Services
Routine Well Child Care
Routine Immunizations
Physicians Services
In-Hospital Visits,
Surgery, Anesthesia,
Diagnostic X-rays & Lab
Services for treatment
in the Emergency Room
Other Covered Services
Durable Medical Equipment,
Physical Therapy,
Ambulance Service
$300 deductible per admission,
100% after deductible
$950 deductible per admission, $50
copay per day, 80% after deductible
80% after deductible
$125 copay, 100% after copay $300 copay, 100% after copay 80% after deductible
$25 copay; 100% after copay
100% of allowed amount;
no deductible or copay
No deductible;
100% of allowed amount
Covered only when provided by
Primary Care Physician
Covered only when provided by
Primary Care Physician
Covered only when provided by
Primary Care Physician
Covered only when provided by
Primary Care Physician
70% after deductible 80% after deductible
$40 copay, then 100% 70% after deductible 80% after deductible
80% after deductible 70% after deductible 80% after deductible
Chiropractic Services
80% after Ded,
limit 12 visits per year
or $400 a year
Not Covered
80% after Ded,
limit 12 visits per year
or $400 a year
Deductibles $500 Individual / $1,500 Family $500 Individual / $1,500 Family $500 Individual / $1,500 Family
Out-of-Pocket Maximum $400 Individual / No family max $400 Individual / No family max $400 Individual / No family max
Mental Health and Substance Abuse
Behavioral Health Systems (BHS) specializes in managing mental
health and substance abuse benefits. BHS has a preferred
provider network of credentialed mental health care providers.
Benefits are available to all persons enrolled and eligible under a
Troy University-sponsored medical plan. To qualify for coverage,
you must be pre-certified and referred through Behavioral Health
Systems. It is your responsibility to make sure that approval is
received from BHS before you are treated. If you do not receive
approval, no benefits will be paid.
To Access Benefits: Call 1-800-245-1150 or visit their website
at www.behavioralhealthsystems.com. Member login is Troysu.
Prescription Drugs
Prescription Drugs (Blue Cross Blue Shield of AL)
Deductible
Individual
No deductible
Family
No deductible
Retail Co-payments
Generic $10.00
Preferred $35.00
Non Preferred $50.00
Mail Order Co-payments
(90 day supply)
Generic $20.00
Preferred $70.00
Non Preferred $100.00
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 4