The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
the opportunity to select the provider. Examples of this situation include diagnostic lab,
independent diagnostic X-ray and independent anesthesia providers.
To locate in-network/participating providers, you may ask your provider if he or she participates
with BCBS, call the BCBS customer service department, or access their Web site*. (See the
“Important Resources” section of this SPD.) In addition, you may call 1-800-810-BLUE (1-800-
810-2583).
It is your responsibility to confirm that the provider you use is an in-network/participating
provider.
* Every effort is made to ensure that the list of providers on the BCBS Web site is up-to-date and accurate.
However, the network is subject to change throughout the year. It is your responsibility to verify that the provider
you or a covered family member uses is in the network associated with your health care option. You should call
BCBS’s customer service department or access their Web site before you receive care to find out if a specific
provider continues to be part of the network.
Example
The following example (if you are enrolled in the Comprehensive option) shows how coverage is
calculated when you use a non-participating or participating provider, assuming your annual
deductible has already been satisfied. In the example, the physician's charges exceed the
Program's allowed amount.
Out-of-Network In-Network
Billed charge for covered service: $100 Billed charge for covered service: $100
Allowed amount: $85 Allowed amount: $85
Non-participating coverage pays 60% $51 Participating coverage pays 80% of $68
of $85:
$85:
You pay $100 minus $51: $49 You pay $85 minus $68: $17
Eligible Health Care Professionals
In order to receive coverage for eligible health care expenses, you need to make sure the
practitioner you are using is eligible. To be eligible, practitioners must practice within the scope
of their licenses and must not be members of your immediate family. Examples of eligible
practitioners include:
• Doctors of medicine (MD) and their supervised employees
• Doctors of chiropractic (DC) and their supervised employees
• Doctors of podiatry (DP or DPM)
• Doctors of optometry (OD)
• Doctors of osteopathy (DO)
• Optometrists
• Licensed acupuncture practitioner
• Licensed psychologists
• Licensed consulting psychologists (LCP)
• Doctors of dental surgery (DDS)
• Certified nurse midwives
• Nurse anesthetists
100