The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
Comprehensive Option
All benefit payments are based on the BCBS allowed amounts. Although this option does not have a BCBS network,
if you use participating BCBS providers, you generally will not be responsible for payment of charges in excess of
the BCBS allowed amount. Please note that eligible services are covered at 80% of the allowed amount regardless if
the provider is participating or non-participating for retirees that are enrolled in Medicare Part A and Medicare Part
B. If a service is not listed, it is likely not a covered service. Please call BCBS of MN if you have questions about
coverage for a specific procedure. Telephone numbers are listed in the “Important Resources” section of this SPD.
Service 1
Participating
Provider After
Deductible
Coinsurance 2
Non-
Participating
Provider After
Deductible
Coinsurance 2 Special Notes
Acupuncture You pay 20% You pay 40% 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 20% You pay 40%
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 20% You pay 40% 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 BCBS of MN
determines air ambulance was not medically necessary but ground
ambulance would have been medically necessary, the Program pays up
to the BCBS of MN allowed amount for ground ambulance.
Benefit
You pay 20% You pay 40% If the benefit substitution of treatment is a prescription drug, see the
Substitution
section “Pharmacy” in this SPD.
Chemical
Dependency/
Substance Abuse
Chiropractic
Services
Cleft Lip and
Palate
Cosmetic,
Reconstructive or
Plastic Surgery
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.
See the “Mental Health and Substance Abuse Coverage” section in this
SPD for more details.
You pay 20% You pay 40% Limited to 25 visits paid by the option per plan year.
You pay 20% You pay 40% Coverage only provided for a dependent child under age 19. Dental
implants and orthodontia services provided as part of the treatment
would be eligible.
You pay 20% You pay 40% Coverage only for reconstructive surgery that is incidental to or follows
surgery resulting from injury, sickness, or other diseases of the involved
body part; reconstructive surgery performed on a dependent child
because of congenital disease or anomaly that has resulted in a
functional defect as determined by the attending physician; or treatment
of cleft lip and palate for a dependent child under age 19. See "Cleft Lip
and Palate" in this chart.
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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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