The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
Early Retiree Medical Option, continued
Service¹
Orthoses —
Custom Only
(Custom-made
Orthopedic Shoes,
Arch Supports and
Foot Orthoses)
Osteopaths
Physical,
Occupational
and Speech
Therapy
Physician/
Professional
Services
2. Vasectomy
Participating
Provider/In-
Network
Coinsurance²
Non-
Participating
Provider/Outof-Network
Coinsurance² Special Notes
You pay 25% You pay 45% Coverage limited to $500 paid by the Program per plan year.
No coverage for over-the-counter products.
You pay 25% You pay 45% If receiving physical therapy or chiropractic services, refer to those
specific services in this chart for benefits.
You pay 25% You pay 45% Limited to 50 visits (in outpatient or office setting) paid by the plan per
plan year for physical and occupational therapy combined unless
additional visits are deemed medically necessary.
You pay 25%
You pay 25%
You pay 45%
Not covered
by the
Program
Limited to 25 visits (in outpatient or office setting) paid by the plan per
plan year for speech therapy unless additional visits are deemed
medically necessary.
No coverage for services primarily educational in nature, vocational
rehabilitation, developmental delay services, self-care and self-help
training (non-medical), health clubs and spas, learning disabilities and
disorders, and recreational therapy or for services not expected to make
measurable or sustainable improvement within a reasonable amount of
time.
Any written prescription written by your provider to be filled at a
pharmacy will be covered by Medco, not BCBS. See the “Pharmacy”
section in this SPD for more information.
Pregnancy and
Prenatal Care
Benefits listed also include visits to convenience clinics such as
MinuteClinic, Take Care or RediClinic.
See “Maternity” in this chart.
Prescription Drugs See the “Pharmacy” section in this SPD.
Preventive Care The Program Not covered See the “Preventive Care” section in this SPD for more information.
pays 100% by the
(no
deductible)
Program
Sleep Studies You pay 25% Not covered No coverage for unattended sleep studies, medically appropriate sleep
by the studies if done at patient’s home, SNAP studies or for overnight pulse
Program oximetry to screen patients for sleep apnea.
Sterilization
See “Physician/Professional Services,” “Hospital Inpatient Services,” or
“Hospital Outpatient Services” in this chart for related services.
1. Tubal Ligation You pay 25% Not covered
by the
Program
Supplies
See “Durable Medical Equipment (DME) and Medical Supplies” in this
chart. Syringes, test strips, lancets and needles are covered by Medco,
not BCBS. See the “Pharmacy” section in this SPD for more
information.
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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