MEDICAL PLUS PLAN FOR RETIREES - Premera Blue Cross

except when medically necessary to treat the
diagnosed substance use disorder or disorders of
a member.
• Halfway houses, quarterway houses, recovery
houses, and other sober living residences
• Outward bound, wilderness, camping or tall ship
programs or activities
• Residential treatment programs or facilities that
are not units of legally-operated hospitals, or that
are not state licensed or approved facilities for the
provisions of residential chemical dependency
treatment
• Residential detoxification
Clinical Trials
This plan covers the routine costs of a qualified
clinical trial. Routine costs mean medically
necessary care that is normally covered under this
plan outside the clinical trial. Benefits are based on
the type of service you get. For example, benefits
for an office visit are covered under the Professional
Visits And Services benefit and lab tests are covered
under the Diagnostic Services benefit.
A qualified clinical trial is a trial that is funded and
supported by the National Institutes of Health, the
Center for Disease Control and Prevention, the
Agency for Healthcare Research and Quality, the
Centers for Medicare and Medicaid Services, the
United States Department of Defense or the United
States Department of Veterans Affairs.
We encourage you or your provider to call customer
service before you enroll in a clinical trial. We can
help you verify that the clinical trial is a qualified
clinical trial. You may also be assigned a nurse
case manager to work with you and your provider.
See "Case Management" for details.
Contraceptive Management and Sterilization
Benefits for female contraceptive management and
female sterilization aren't subject to any cost-shares
(see "Definitions") when you use a network provider.
Benefits for male contraceptive management and male
sterilization are subject to your calendar year deductible
and coinsurance when you use a network provider.
Please Note: If the contraceptive management or
sterilization services and supplies are furnished by a
non-network provider or medical facility, benefits are
subject to your calendar year deductible and
coinsurance. For an explanation of the amount
you’ll pay for services and supplies from nonnetwork
providers, please see the "What Are My
Benefits" section of this booklet.
This benefit covers the following services and
supplies received from a health care provider:
• Office visits and consultations related to
contraception
• Injectable contraceptives and related services
• Implantable contraceptives (including hormonal
implants) and related services
• Emergency contraception methods (oral or
injectable)
• Sterilization procedures. When sterilization is
performed as the secondary procedure,
associated services such as anesthesia and
facility charges will be subject to your cost-shares
under the applicable facility benefit and are not
covered by this benefit.
Prescription Contraceptives Dispensed By A
Pharmacy
Prescription contraceptives (including emergency
contraception) and prescription barrier devices or
supplies that are dispensed by a licensed pharmacy
are covered under the Prescription Drugs benefit.
Your normal cost-share is waived for these devices
and for generic and single-source brand name birth
control drugs when you get them from a participating
pharmacy. Examples of covered devices are
diaphragms and cervical caps.
The Contraceptive Management and Sterilization
benefit doesn’t cover:
• Non-prescription contraceptive drugs, supplies or
devices (except emergency contraceptive methods)
• Prescription contraceptive take-home drugs
dispensed and billed by a facility or provider's
office
• Hysterectomy. (Covered on the same basis as
other surgeries. See the Surgical Services benefit.)
• Sterilization reversal
Testing, Diagnosis and Treatment of Infertility
Benefits are provided for infertility testing, diagnosis
and treatment, including related imaging and
laboratory services, up to a lifetime maximum benefit
of $5,000 per member.
Benefits for the following infertility services are
subject to your calendar year deductible and
coinsurance:
• Inpatient Facility Services
Note: Please have your provider notify Customer
Service before inpatient admission to a facility or
within 48 hours of emergency admission to a facility.
• Inpatient Professional Services
• Outpatient Surgical Facility Services
• Testing and Surgical Procedures
• Outpatient Professional Visits
• Other Professional Services
When two eligible members are involved in the
treatment, the costs of the services are accumulated
to each member’s benefit maximum as follows:
Weyerhaeuser – Medical Plus Plan for Retirees - 7 -
January 1, 2014