The eligibility and enrollment rules for the U

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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. 36
Retiree Health Care SPD Effective January 1, 2012 Early Retiree Medical Option, continued Service¹ Participating Provider/In- Network Coinsurance² Non- Participating Provider/Outof-Network Coinsurance² Special Notes TMJ Services You pay 25% You pay 45% $5,000 lifetime maximum paid by plan per person for all related services, including Orthognathic surgery. Related physical therapy services are paid under the Physical Therapy benefit and do not apply to the TMJ Transplants You pay 25% Not covered by the Program Urgent Care You pay 25% You pay 45% Weight Loss Treatment 1. Age 18 and older 2. Under age 18 You pay 25% You pay 25% Not covered by the Program You pay 45% lifetime maximum. See the “Transplants” section in this SPD for important coverage information. Coverage is limited to bariatric surgery for severe and morbid obesity. Coverage limited for Panniculectomy. See “Cosmetic, Reconstructive or Plastic Surgery” in this chart as well as the “Bariatric Surgery” section in this SPD for important coverage information and requirements. No coverage for weight loss and diet programs of any type. 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. 37
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The eligibility and enrollment rules for the U

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