Blue Cross & Blue Shield of Mississippi | Network Blue Outline of Benefits

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Healthy You! Covered Screenings (Males)
Services are covered once per calendar year unless otherwise noted.		Birth-24 months	2-11 years	12-17 years	18-39 years	40-49 years	50+ years
Preventive medicine evalution or re-evaluation		8 visits	•	•	•	•	•
Hemoglobin, hematocrit or CBC		•	•	•	•	•	•
Urinalysis		•	•	•	•	•	•
Immunizations (Coverage varies by age.)		•	•	•	•	•	•
Blood pressure			•	•	•	•	•
Glucose (High risk ages 3-39.)			•	•	•	•	•
Lipid profile (High risk ages 2-17.)			•	•	•	•	•
Prostate specific antigen with digital rectal exam.						•	•
Stool for occult blood						•	•
Flexible sigmoidoscopy (Every 5 Years) or Colonoscopy (Every 10 Years)							•

Healthy You! Covered Screenings (Females)
Services are covered once per calendar year unless otherwise noted.	Birth-24 months	2-11 years	12-17 years	18-34 years	35-39 years	40-49 years	50+ years
Preventive medicine evaluation or re-evaluation	8 visits	•	•	•	•	•	•
Hemoglobin, hematocirt or CBC	•	•	•	•	•	•	•
Urinalysis	•	•	•	•	•	•	•
Immunizations (Coverage varies by age.)	•	•	•	•	•	•	•
Blood pressure		•	•	•	•	•	•
Breast exam			•	•	•	•	•
Pap smear and pelvic exam			•	•	•	•	•
Glucose (High risk ages 3-39.)		•	•	•	•	•	•
Lipid profile (High risk ages 2-17.)		•	•	•	•	•	•
Mammogram					•	•	•
Stool for occult blood						•	•
Bone Density (Once per lifetime.)							•
Flexible sigmoidoscopy (Every 5 Years) or Colonoscopy (Every 10 Years)							•

Healthy You! wellness benefits do not apply to services rendered by non-Network Providers. For detailed information regarding screenings, visit the Healthy You! page.

Network Blue Outline of Benefits
Benefit Period	Calendar Year
Calendar Year	No Limit
Calendar Year Medical Deductible Options	Individual: $250; $500; $750; $1,000; $1,500; $2,000; $2,500; $3,000; $3,500; $4,000; $5,000; $7,500 or $10,000 Family: 3 times the Individual Amount
	Network Provider	Non-Network Provider
Calendar Year Prescription Drug Deductible Options (Varies, based on medical deductible)	$0; $50; $100; $150; $200; $250; $500; $1,000; $1,500; $2,000; $2,500	Not covered
Calendar Year Out-of-Pocket Options	Individual: $1,000; $1,500; $2,000; $2,500; $5,000; $10,000 Family: 3 times the Individual Amount	No limit for out-of-network
Benefits/Co-insurance Options	90% 80% 70%	70% 60% 50%
Healthy You! Wellness Benefit Services based on age and gender For a complete listing of the Healthy You! screening guidelines, visit the Healthy You! page.	100% with no co-pay, co-insurance or deductible.	Not covered
Outpatient Prescription Drugs
	Community PLUS Pharmacy	Non-Community PLUS Pharmacy
*be RxSmart. it's your choice*._sm
Category 1-Generally includes low-cost generic and some brand name drugs.	$10 or $15	No benefits
Category 2-Generally includes higher-cost generic and many brand-name drugs.	$25 or $35	No benefits
Category 3-Generally includes some brand-name drugs and some generic drugs. These drugs may have generic or brand-name alternatives in Category 1 or 2.	$50 or $75	No benefits
Category 4-Generally includes high cost generic drugs, high cost technology drugs and specialty drugs.	$100	No benefits
Maintenance Medications (90-day supply)	100% after 2.5 times co-pay for generic medications. 100% after 3 times co-pay for brand medications Must use Community PLUS Maintenance Pharmacies	No benefits
Generic First / Generic Only	Some brand name medication will not be covered if there is a generic equivalent. Some brand name medication will be covered only after a similar generic medication is prescribed first.	No benefits
Disease Specific Drugs
	Network Provider	Non-Network Provider
Drugs must be provided by a Network Disease Specific Pharmacy or a Member’s Non-Pharmacy Network Provider, have been Prior Authorized by the Company, and listed in the Disease Specific Drug Formulary	100% after 10% of the Allowable Charge or Varying Co-payment whichever is less, up to an annual $10,000 Disease Specific Drug Out-of-pocket, then a Varying Co-payment	No benefits
Covered Services	Network Provider	Non-Network Provider
Physician (MD or DO) Office Visit Co-pay Options Applies to the office visit only. Co-pay amounts do not accrue toward the deductible	Primary Care Physician: $15, $20, $25, $30, $40, $50 Specialist: $20, $25, $30, $40, $50	Co-pay does not apply
Physician Office Services (MD or DO) Office Visits Only - Other than Preventive/Wellness. Other Office Services - Other than Preventive/Wellness. Includes injections, X-ray/lab, surgery, etc.	100% after Co-pay Deductible Waived Benefits/Co-insurance Deductible Waived	Benefits/Co-insurance Deductible Applies
Newborn Well Baby Care - Exams and routine hospital nursery care of a well newborn.	Benefits/Co-insurance Deductible Applies	$100 Per Admission Deductible, plus Benefits/Co-insurance Deductible Applies
Hospital Inpatient Services	Benefits/Co-insurance Deductible Applies	$100 Per Admission Deductible, plus Benefits/Co-insurance. Deductible Applies
Emergency Room Services	Benefits/Co-insurance Deductible Applies	Benefits/Co-insurance Deductible Applies
Ambulatory Surgical Facility Services	Benefits/Co-insurance Deductible Applies	Benefits/Co-insurance Deductible Applies
Allied Primary Care Health Professional - Nurse Practitioner / Nurse Midwife / Physician Assistants Office Visits - Co-pay does not apply to any other services rendered in the office. Other Office Services - Deductible does not apply to services rendered by a Network Provider.	100% after Co-pay Benefits/Co-insurance Deductible Waived	Benefits/Co-insurance Deductible Applies
Allied Specialists - Optometrists, Chiropractors, Podiatrists Limited to 20 visits per calendar year for physical medicine services from chiropractors, physical therapists and occupational therapists. Office Visits - Co-pay does not apply to any other services rendered in the office. Other Office Services - Deductible does not apply to servicess rendered by a Network Provider.	100% after Co-pay Benefits/Co-insurance Deductible Waived	Benefits/Co-insurance Deductible Applies
Approved Allied Services DME, Ambulance, Prosthetics/Orthotics, etc.	Benefits/Co-insurance Deductible Applies	Benefits/Co-insurance Deductible Applies
Diabetes Treatment - Must have a diagnosis of diabetes. Equipment, supplies for monitoring of blood glucose and insulin administration - Home glucose monitors limited to 1 every 2 calendar years. Prescription Drug Benefits will be provided for diabetic supplies (blood testing, urine testing, and lancets). Self-Management Training / Education and Medical Nutrition Therapy - one per calendar year. Dilated Eye Exam - one exam per calendar year. Preventive Routine Foot Care - one visit per calendar year.	Benefits/Co-insurance Deductible Applies	Benefits/Co-insurance Deductible Applies
Approved Therapy Services Chemotherapy, Radiation, etc.	Benefits/Co-insurance Deductible Applies	Benefits/Co-insurance Deductible Applies
TMJ Lifetime Maximum: $5,000 Covered charges do not accure toward the out-of-pocket amount. Co-pays are applicatble to Network Physician Office Visits	Benefits/Co-insurance Deductible Applies	Benefits/Co-insurance Deductible Applies
Physical Medicine - Limited to 20 visits per calendar year; combined with Allied Specialist visits.	Benefits/Co-insurance Deductible Applies	Benefits/Co-insurance Deductible Applies
Organ Transplant - No benefits provided without prior approval and case management. Donor Benefits	Benefit/Co-insurance Deductible Applies	Not Covered
Hospice Care Limited to 6 months per lifetime, subject to case management	Benefit/Co-insurance Deductible Applies	Not Covered
Nervous / Mental Care*
Hospital Inpatient Care - Not to exceed 30 days per calendar year.	Benefits/Co-insurance Deductible Applies	Benefits/Co-insurance Deductible Applies
Partial Hospitalization - Maximum of 60 days per calendar year. "Partial" means admission for less than 24 hours.	Benefits/Co-insurance Deductible Applies	Benefits/Co-insurance Deductible Applies
Hospital Outpatient Visits - Maximum of 52 visits per calendar year; combined with Physician Office Visits.	Benefits/Co-insurance Deductible Applies	50% Deductible Applies
Other Physician Outpatient Services	50% Deductible Applies	50% Deductible Applies
Physician Office Visits - Maximum of 52 visits per calendar year combined with hospital outpatient maximum.	100% after Co-pay	50% Deductible Applies
Other Services Rendered in Physician's Office	Benefits/Co-insurance Deductible Applies	50% Deductible Applies

*These benefits are applicable to groups with 50 or fewer members. For large groups, these benefits are the same as standard Medical Benefits. Prior Authorization is required for these benefits.

This summary of the Network Blue Benefit Plan is designed for the purpose of presenting general information about the Benefit Plan and is not intended as a guarantee of benefits. It is not a Summary Plan Description and in the event of a conflict between this document and the actual Benefit Plan, the terms of the Benefit Plan will prevail.