The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
Early Retiree Medical Option, continued
Service¹
Lab, X-ray, CT
Scans, MRI and
Nuclear Imaging
1. Illness-Related
2. Preventive Care
Mastectomy and
Reconstructive
Surgery
Maternity
1. Hospital
Services (Inpatient
or Outpatient) and
Postpartum Office
Visits
2. Prenatal Office
Visits
Participating
Provider/In-
Network
Coinsurance²
You pay 25%
The Program
pays 100%
(no
deductible)
Non-
Participating
Provider/Outof-Network
Coinsurance² Special Notes
See “Maternity” in this chart for prenatal lab and x-ray services.
You pay 45%
Not covered
by the
Program
Services are paid based on the billing codes used by your provider on the
claim submitted to the medical Claims Administrator for payment.
If a non-participating/out-of-network provider performs the procedure
and then sends it out to be read, the charges for the reading only will be
paid at the participating/in-network level.
When submitted with an illness diagnosis code.
See the “Preventive Care” section in this SPD for more information.
You pay 25% You pay 45% See special notice in the section “The Woman’s Health and Cancer
Rights Act of 1998” in this SPD.
You pay 25%
The Program
pays 100%
(no
deductible)
You pay 45%
You pay 45%
Coverage is the same as for illness. Pregnancy coverage ends when your
coverage under your plan otherwise ends for any reason. New
dependents must be added within 60 days of birth to be covered (see
the “Eligibility and Enrollment section” section in this SPD).
Inpatient benefits will not be restricted to less than 48 hours from the
time of vaginal delivery or 96 hours from the time of Cesarean section
delivery. Refer to the “Inpatient Maternity Care” section in this SPD for
further details. You are allowed one home health visit upon discharge.
(See “Home Health Care” in this chart for additional information.)
Prenatal lab and x-ray services are paid based on where the services are
performed. If in a facility, they will pay under the Hospital Services
benefit. If in an office, they will pay under the Prenatal Office Visits
benefit.
No coverage for adoption or adoption-related expenses, surrogate
pregnancy or related expenses, childbirth classes, or delivery at home.
Mental Health You pay 25% You pay 45% See the “Mental Health and Substance Abuse Coverage” section in this
Nutritional
Counseling
Orthoptic Training
(Eye muscle
exercise)
SPD for more details.
You pay 25% You pay 45% Covered when provided by a registered dietician to develop a dietary
treatment plan to treat and/or manage medical conditions that require a
special diet (e.g., anorexia, diabetes, gout, etc.).
You pay 25% You pay 45%
No coverage for non-disease specific counseling, nutritional education
such as general good eating habits, calorie control or dietary preferences.
Training must be provided by a licensed optometrist or an orthoptic
technician.
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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