The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 Comprehensive Option, continued Service 1 Nutritional Counseling Orthoptic Training (Eye muscle exercise) Orthoses — Custom Only (Custom-made Orthopedic Shoes, Arch Supports and Foot Orthoses) Osteopaths Physical, Occupational and Speech Therapy Physician/ Professional Services Participating Provider After Deductible Coinsurance 2 Non- Participating Provider After Deductible Coinsurance 2 Special Notes You pay 20% You pay 40% 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.). No coverage for non-disease specific counseling, nutritional education such as general good eating habits, calorie control or dietary preferences. You pay 20% You pay 40% Training must be provided by a licensed optometrist or an orthoptic technician. You pay 20% You pay 40% Coverage limited to $500 paid by the Program per plan year. No coverage for over-the-counter products. You pay 20% You pay 40% 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. 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. You pay 20% You pay 40% 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 Clinical Visits 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 by See the “Preventive Care” section in this SPD for more information. pays 100%(no deductible) the Program Sleep Studies You pay 20% Not covered by No coverage for unattended sleep studies, medically appropriate sleep the Program studies if done at patient’s home, SNAP studies or for overnight pulse oximetry to screen patients for sleep apnea. 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. 44
Retiree Health Care SPD Effective January 1, 2012 Comprehensive Option, continued Sterilization 1. Tubal Ligation 2. Vasectomy Supplies TMJ Services You pay 20% You pay 20% Not covered by the Program Not covered by the Program See “Physician/Professional Services,” “Hospital Inpatient Services,” or “Hospital Outpatient Services” in this chart for related services. 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. You pay 20% You pay 40% $5,000 lifetime maximum paid by the Program per person for all related services, including Orthognathic surgery. Related physical therapy services are paid under the Physical Therapy benefit and do Transplants You pay 20% Not covered by the Program Urgent Care Weight Loss Treatment You pay 20% You pay 40% 1. Age 18 and older 2. Under age 18 You pay 20% You pay 20% Not covered by the Program You pay 40% not apply to the TMJ lifetime maximum. See the “Transplants” section later 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. 45
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The eligibility and enrollment rules for the U

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