Precertification required for visits by home health professional outside Alabama. Speech Therapy (Occupational, physical and speech therapy limited to a combined maximum of 30 visits per year). Occupational and Physical Therapy (Occupational, physical and speech therapy limited to a combined maximum of 30 visits per year). Physician services for the treatment of mental health and substance abuse.īenefits for Other Covered Services BenefitsĬovered at 80% subject to calendar year deductible in Alabama, covered at 50% subject to calendar year deductible.Out-of-Network outpatient hospital services.$400 individual certain benefits pay at 100% of the allowed amount thereafter. Out-of-network physician services outside of Alabama.Inpatient Physician services for mental health and substance abuse treatment.$200 individual $600 aggregate maximum per family.Ĭalendar Year Out-of-Pocket Maximum Applies to: Summary of Cost Sharing Provisions Calendar Year Deductible Applies to: Note: To view the most current Preferred Drug List or Maintenance Drug List, visit Then select “I am a Customer,” and on the next screen under Prescription Drug Reference, select “Prescription Drug Guide.” Some co-pays combined for diabetic supplies. Note: In case of illness or family history of cancer, services generally are not considered preventive and may be covered by the other plan provisions.īlue Cross Maintenance List Drugs – up to a 60 day supply. (Outpatient hospital services may require a co-pay). *Double-contrast barium enema every five yearsĬovered at 100% no co-pay or deductible for physician changes. *Flexible sigmoidoscopy every three years Routine PSA (Prostate Specific Antigen) (One per year for males age 40 and over). (One exam for females ages 35-39 and one per year for females ages 40 and over). Routine Office Visits (When eligible for routine pap smear, routine mammogram, or routine PSA). (Age limitations apply to certain immunizations). (Nine visits during first 24 months of life and one visit each year thereafter through age six).Ĭovered at 100% no deductible, subject to a $30 copayment. Note: In Alabama, Out-of-Network physician services covered at 50% subject to calendar year deductible. (Office visit co-pay applies to initial visit to confirm pregnancy).ĭiagnostic Lab, X-Ray, Pathology, IV Therapy, Chemotherapy & Radiation Therapy Outpatient Diagnostic Lab, X-Ray, Pathology, IV Therapy, Chemotherapy & Radiation TherapyĬovered at 80% subject to calendar year deductible. Inpatient Physician Visits & ConsultationsĬovered at 80% subject to calendar year deductible.Ĭovered at 100% after $25 facility co-pay.Ĭovered at 80% subject to calendar year deductible in Alabama, not covered.Ĭovered at 100% no co-pay or deductible.Ĭovered at 100% no co-pay or deductible for services within 72 hours thereafter 80% subject to calendar year deductible.Ĭovered at 100% after $30 physician co-pay. Note: In Alabama, Out-of-Network benefits available only for accidental injury. Note: Inpatient hospital deductibles and co-pays do not apply to the calendar year out-of-pocket maximumġ00% of the allowed amount, subject to a $100 deductible per admission and a $50 copayment for the 2nd through the 6th days.Ĩ0% of the allowed amount, subject to a $200 deductible per admission. Providers can be located at by calling BCBS at 1-800-810-BLUE. BCBS will issue the new cards to your home. This is important for employees who travel or have dependents attending college outside of Alabama. Call 1-80 (toll free) for precertification.īlue Card PPO extends your PMD benefits outside of Alabama. Preadmission Certification is required for inpatient admissions (except maternity): notification within 48 hours for emergencies. Prescription Drug Benefits will now be covered by CVS Caremark. Out of pocket Max $1500 Individual ($4500 Family)Ĭopays and Deductible DO NOT apply to OOP Max Outpatient Physician Office Visits: $35 copay (Primary Care) $50 copay (Specialist) Outpatient Physician Office Visits: $30 copay Outpatient Surgery: Covered at 100% after $250 hospital copay Outpatient Surgery: Covered at 100% after $25 hospital copay Inpatient Hospital: Covered at 100% of the allowed amount, subject to the calendar year deductible $50/day copays days 2-6 for each admission Inpatient Hospital: Covered at 100% after $100 per admission deductible $50/day hospital copay days 2-6 for each admission Health Benefits – Blue Cross Blue Shield of Alabama (BCBS) - Group #88942Įmergency Room (Medical Emergency):Covered at 100% after $25 copayĮmergency Room (Medical Emergency): Covered at 100% after $100 copayĮmergency Room (Accident): Covered at 100%: no copay or deductibleĮmergency Room (Accident): Covered at 100% after $100 hosptial copay
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