EOC - Erlanger Health System

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NOTICE PLEASE READ THIS EVIDENCE OF COVERAGE CAREFULLY AND KEEP IT IN A SAFE PLACE FOR FUTURE REFERENCE. IT EXPLAINS YOUR BENEFITS AS ADMINISTERED BY BLUECROSS BLUESHIELD OF TENNESSEE, INC. IF YOU HAVE ANY QUESTIONS ABOUT THIS EVIDENCE OF COVERAGE OR ANY OTHER MATTER RELATED TO YOUR MEMBERSHIP IN THE PLAN, PLEASE WRITE OR CALL US AT: CUSTOMER SERVICE DEPARTMENT BLUECROSS BLUESHIELD OF TENNESSEE, INC., ADMINISTRATOR 1 CAMERON HILL CIRCLE CHATTANOOGA, TENNESSEE 37402-2555 (800) 565-9140 Erlanger Health System 2009
Erlanger Health System 2009
Page 1: ERLANGER HEALTH SYSTEM Health Benef
Page 5 and 6: INTRODUCTION This Evidence of Healt
Page 7 and 8: ELIGIBILITY Any Employee of the Emp
Page 9 and 10: EFFECTIVE DATE OF COVERAGE If You a
Page 11 and 12: SUBROGATION AND RIGHT OF REIMBURSEM
Page 13 and 14: BLUECARD/BLUECARD PPO PROGRAM When
Page 15 and 16: CLAIMS AND PAYMENT When You receive
Page 17 and 18: PRIOR AUTHORIZATION, CARE MANAGEMEN
Page 19 and 20: Your concern will be noted and inve
Page 21 and 22: the Termination of Coverage Section
Page 23 and 24: COORDINATION OF BENEFITS This EOC i
Page 25 and 26: (1) First, the Plan of the parent w
Page 27 and 28: of This Plan and such rule states t
Page 29 and 30: II. DESCRIPTION OF THE REVIEW PROCE
Page 31 and 32: DEFINITIONS Defined terms are capit
Page 33 and 34: 24. Employee - A person who fulfill
Page 35 and 36: Investigational Service. If the Med
Page 37 and 38: difference between Billed Charges a
Page 39 and 40: ATTACHMENT A: COVERED SERVICES AND
Page 41 and 42: C. Office Surgery Medically Necessa
Page 43 and 44: injections; (7) fertility drugs, (8
Page 45 and 46: The following Medically Necessary a
Page 47 and 48: d. If You receive Prior Authorizati
Page 49 and 50: d. Items to replace those that were
Page 51 and 52: 3. Three intensive outpatient progr
Page 53 and 54:
syringes used in conjunction with i
Page 55 and 56:
k. Maintenance Drug - Prescription
Page 57 and 58:
EVIDENCE OF COVERAGE ATTACHMENT B:
Page 59 and 60:
EVIDENCE OF COVERAGE ATTACHMENT C:
Page 61 and 62:
(Family/General Practice, Internal
Page 63 and 64:
Other Wellcare Screenings, age 6 an
Page 65 and 66:
Schedule of Pharmacy Prescription D
Page 67 and 68:
Miscellaneous Limits: In-Network Se
Page 69 and 70:
Diagnostic Services and Preventive
Page 71 and 72:
Services Received at a Facility Inp
Page 73 and 74:
Organ Transplant Services Organ Tra
Page 75 and 76:
Benefit percentages apply to BCBST
Page 77 and 78:
EVIDENCE OF COVERAGE ATTACHMENT C:
Page 79 and 80:
(Family/General Practice, Internal
Page 81 and 82:
Other Wellcare Screenings, age 6 an
Page 83 and 84:
Schedule of Pharmacy Prescription D
Page 85 and 86:
Miscellaneous Limits: In-Network Se
Page 87 and 88:
the U. S. Department of Labor, or m
Page 89 and 90:
UNIFORMED SERVICES EMPLOYMENT AND R
Page 91 and 92:
MARKETING: Your medical information
Page 93:
www.bcbst.com BENEFIT QUESTIONS? Ca
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EOC - Erlanger Health System

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