The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
WHAT THE OPTIONS COVER
Early Retiree Medical Option
The benefit charts on the next several pages describe the services for the Early Retiree Medical
option. You are responsible for paying the difference between the provider’s billed charge and
the BCBS allowed amount when using non-participating providers. In certain locations, this also
applies when out-of-network providers are used. See the section “Which Network Providers to
Use” in this SPD for more information. If a service is not listed, it is likely not a covered service.
Please call your medical Claims Administrator if you have questions about coverage for a
specific procedure. Telephone numbers are listed in the “Important Resources” section in this
SPD.
Service¹
Participating
Provider/In-
Network
Coinsurance²
Non-
Participating
Provider/Outof-Network
Coinsurance² Special Notes
Acupuncture You pay 25% You pay 45% Coverage is limited to pain management only and services must be
provided as part of a comprehensive pain management program after
all other treatment options have failed. Coverage also provided for
prevention and treatment of nausea associated with surgery,
chemotherapy or pregnancy.
Allergy Testing
and Treatment
You pay 25% You pay 45%
No coverage for therapeutic acupuncture, weight loss management,
smoking cessation or other non-listed purposes.
Coverage provided for testing, serum, and allergy shots.
Ambulance You pay 25% You pay 25% Coverage is limited to air or ground transportation from the place of
departure to the nearest facility equipped to treat the illness, and to
prearranged medically necessary air or ground ambulance
transportation requested by an attending physician or nurse. If the
Claims Administrator determines air ambulance was not medically
necessary but ground ambulance would have been medically
necessary, the plan pays up to the BCBS allowed amount for ground
ambulance.
Benefit
You pay 25% You pay 45% If the benefit substitution of treatment is a prescription drug, see the
Substitution
“Pharmacy” section in this SPD.
Chemical
Dependency/
Substance Abuse
Chiropractic
Services
Cleft Lip and
Palate
Benefit substitution is a course of treatment approved and authorized
by a BCBS case manager as an alternative to the services and supplies
that would otherwise have been covered by the Program. The benefit
substitution must be at a cost equal to or lower than that of the care
being provided and maintain the same quality of care. Failure to
follow an approved treatment plan may result in nonpayment of
services. Call the customer service number on your ID card for
further information.
You pay 25% You pay 45% See the “Mental Health and Substance Abuse Coverage” section in
this SPD for more details.
You pay 25% You pay 45% Limited to 25 visits paid by the plan per plan year.
You pay 25% You pay 45% Coverage only provided for a dependent child under age 19. Dental
implants and orthodontia services provided as part of the treatment
would be eligible.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
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