The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 physical examination would normally have been provided in the absence of the third party request. 55. Admission for diagnostic tests that can be performed on an outpatient basis unless medically necessary. 56. Inpatient hospital room and board expenses that exceeds the semi-private room rate, unless a private room is approved by BCBS as medically necessary. 57. Services for or related to cosmetic health services or reconstructive surgery and related services and treatment for conditions or problems related to cosmetic surgery or services, except as specified in the benefit charts in this SPD. 58. Membership costs for health clubs, weight loss clinics and similar programs. 59. Services for or related to commercial weight loss programs, fees or dues, nutritional supplements, food, vitamins and exercise therapy, and all associated labs, physician visits, and services related to such programs. 60. Nutritional counseling, except as specified in the benefit charts in this SPD. 61. Charges for or relating to refractive eye surgery when the only goal is to minimize or eliminate dependence on glasses or contact lenses in otherwise non-diseased corneas, including laser surgery to correct myopia (nearsightedness), myopic astigmatism, and/or hyperopia (farsightedness). 62. Services for or related to lenses, frames, contact lenses, and other fabricated optical devices or professional services for the fitting and/or supply thereof, including the treatment of refractive errors such as radial keratotomy, except as specified in the benefit charts in this SPD. 63. Dentures and dental implants, regardless of the cause or condition, and any associated services and/or charges including bone grafts, except as specified in the benefit charts in this SPD. 64. Bone grafts for the sole purpose of supporting a dental implant, except as specified in the benefit charts in this SPD. 65. Services for or related to dental or oral care, implants, treatment, orthodontia, surgery and any related supplies, anesthesia and facility charges, except as specified in the benefit charts in this SPD. 66. Services for or related to reversal of sterilization. 67. Services for or related to sex transformation/gender reassignment surgery, sex hormones related to the surgery, related preparation and follow-up treatment, or care and counseling. 68. Charges for giving injections that can be self-administered. 106
Retiree Health Care SPD Effective January 1, 2012 69. Drugs identified as not covered in the “Pharmacy” section in this SPD. 70. All services, treatments, devices or supplies identifiable as being provided in conjunction with a benefit or service that is not covered. 71. Medical treatment or services identified as not covered in the benefit charts in this SPD. This is not intended to be an exhaustive list. If you have a question on what your option will cover, call the BCBS customer service department at the number listed in the “Important Resources” section in this SPD. Using Your ID Card When Traveling Note: This section does not apply to the Kaiser Colorado option or the Medica or UnitedHealthcare Plan options. If you are enrolled in the Kaiser option or Medica or UnitedHealthcare option, you should refer to the materials provided to you by Kaiser, Medica or UnitedHealthcare to determine the provisions and requirements of these benefit options. If you are traveling, whether within the United States or internationally, do not forget to carry your medical plan ID card. When you receive care from a BCBS BlueCard PPO or “participating” provider within the United States, your claims will automatically be submitted to BCBS for you, and you generally will not be responsible for any dollars the physician charges in excess of the Program's allowed amounts. In a few locations, however, you are responsible for the difference between the allowed amount and the amount charged, if greater. In addition, consistent with state law, in a small number of states, BCBS uses a basis for calculating your payment for covered services that does not reflect the entire discount realized or expected to be realized on a particular claim. When you receive covered health services in those states, the amount you are required to pay will be calculated using these methods. The benefits you receive will depend on the option you have, the provider you use and the service you receive. It is recommended that you contact BCBS for specific information before you travel. It is important that you show your ID card to the provider at the time you receive services because the suitcase logo pictured on the front of the ID card allows you the same level of benefit as those received within your home state. You can also use your medical ID card when you receive health care services with participating providers in many countries outside the United States. This is called BlueCard Worldwide ® . Details on BlueCard Worldwide ® can be found online or by calling customer service (see the “Important Resources” section in this SPD). Address Changes If You Spend Time in Another Part of the Country If you spend time in another part of the country, it is important that you contact the U.S. Bank Employee Service Center at 1-800-806-7009. You can have two addresses on file at the Employee Service Center, a permanent address and an alternate address. You will need to designate which address you want to be your mailing address. Designating the appropriate 107
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