| Outline of Benefits | ||
|---|---|---|
| Benefit Period | Calendar Year | |
| Maximum Out-of-Pocket and Coinsurance Options | ||
|
|
Network Provider | Non-Network Provider |
| Calendar Year Maximum Out-of-Pocket (including Deductible) After the Calendar Year Maximum Out-of-Pocket is met, applicable in-network expenses are covered at 100% for the remainder of the calendar year. |
Individual: $9,450 Family: 2 times the Individual Amount |
Not applicable for services rendered by Out-of-Network Providers |
| Coinsurance Options | 60% |
50% |
| Deductible Options | ||
| Combined Calendar Year Medical and Prescription Drug Deductible Option | Individual: $5,450 Family: 2 times the Individual Amount |
Individual: 2 times the Network Amount Family: 2 times the Non-Network Individual Amount |
| Health and Wellness | ||
| Covered Services | Healthy You! Network Provider | Non-Network Provider |
| Healthy You!
Wellness Services based on age and gender. For a complete listing of the Healthy You! screening guidelines, visit the Healthy You! page. Other Preventive Health Services as outlined in Medical Policy are also covered. |
100% with no co-pay, coinsurance or deductible. | Not covered |
| Covered Services | Color Me Healthy! Network Provider | Non-Network Provider |
| Color Me Healthy! Outpatient Services for eligible Members enrolled in the Color Me Healthy! Benefit. |
100% | Not Covered |
| Diabetes Treatment 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 - six (6) hours per calendar year. Dilated Eye Exam - one exam per calendar year. Preventive Routine Foot Care - one visit per calendar year. |
60% Deductible Applies |
Not Covered |
| Prescription Drugs | ||
| Benefits are provided for Prescription Drugs included in the Prescription Drug Formulary and Maintenance Formulary. |
||
| be RxSmart. it's your choice.sm | Community PLUS Pharmacy | Non-Community PLUS Pharmacy |
| Category 1-Generally includes low-cost generic and some brand name drugs. | $10 Deductible Waived |
Not Covered |
| Category 2-Generally includes higher-cost generic and many brand-name drugs. | 60% Deductible Applies |
Not Covered |
| 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. | 60% Deductible Applies |
Not Covered |
| Category 4-Generally includes high cost generic drugs, high cost technology drugs and specialty drugs. | 60% Deductible Applies |
Not Covered |
| Maintenance Medications (90-day supply) Must use Community PLUS Maintenance Pharmacies |
60% Deductible Applies |
Not Covered |
| Generic Only | Certain brand name or Reference Biologic Medications will not be covered if there is an available generic equivalent, Interchangeable Biological Product or Biosimilar Product. | Not Covered |
| Generic First | Certain prescribed medications with generic, Interchangeable Biological Product, Biosimiliar Product or lower cost alternative may only be covered if the generic alternative, Interchangeable Biological Product or Biosimiliar Product is prescribed first. | Not Covered |
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 |
60%
Deductible Applies |
Not Covered |
|
Medical Specialty Drugs
|
||
| Network Provider | Non-Network Provider | |
| Drugs must be dispensed or administered by a Hospital, Physician or Allied Provider and listed in the Medical Prescription Drug Formulary. Deductible does not apply when dispensed or administered in the Network Physician’s or Network Allied Provider’s Office. *Non-Network Benefits vary according to place of service. No Benefits will be provided if the Non-Network Provider’s services are not covered. |
Coinsurance
Deductible Applies |
50% Deductible Applies or Not Covered* |
Medical Services |
||
| Prior Authorization must be obtained by a Network Provider for non-emergent elective services provided outside the State of Mississippi unless the member lives out of state. |
||
| Specialty Services | ||
| Specialty Services include, but are not limited to: Cardiac Care; Spine Surgery; and Orthopedic Services. All Specialty Services are subject to prior authorization, a determination by Blue Cross & Blue Shield of Mississippi of the most clinically appropriate setting, and are only covered at the higher benefit level if performed by a Center of Excellence Provider or Blue Specialty Network Provider. |
||
|
Blue Specialty Network Provider* |
Non-Blue Specialty Network Provider | Non-Network Provider |
| 70% Deductible Applies |
50% Deductible Applies |
Not Covered |
| *Services include certain Specialty Services which are Ambulatory Services performed in a non-hospital setting approved and designated by Blue Cross & Blue Shield of Mississippi. To be covered, certain Specialty Services to include hip, knee and shoulder replacement and spine surgeries, must be provided by a Blue Specialty Network Provider. |
||
|
Center of Excellence Provider** |
Non-Center of Excellence Network Provider | Non-Network Provider |
| 70% Deductible Applies |
50% Deductible Applies |
Not Covered |
| **Only certain Specialty Services are covered in the Hospital Inpatient or Outpatient settings and only if supported by Medical Policy, including Medical Necessity, and a determination by the Company of the most clinically appropriate setting. |
||
| Hospital Services | ||
|
Covered Services
|
Network Provider | Non-Network Provider |
| Inpatient Hospital Services | 60% Deductible Applies |
50% Deductible Applies |
| Outpatient Hospital Services | 60% Deductible Applies |
50% Deductible Applies |
| Emergency Room Services - Non-emergent services are subject to the Non-Network Provider Coinsurance amount. |
60%
Deductible Applies |
60% Deductible Applies |
| Newborn Well Baby Care - Exams and routine hospital nursery care of a well newborn. |
60% Deductible Applies |
50% Deductible Applies |
| Ambulatory Facility Services | ||
| Ambulatory Surgical Facility Services |
60%
Deductible Applies |
50% Deductible Applies |
| Physician and Allied Professional Services | ||
|
Covered Services |
Network Provider | Non-Network Provider |
| Physician and Allied Professional Office Visit Coinsurance | Primary Care: 60% Specialist: 60% Deductible Applies |
50% Deductible Applies |
| Physician Office Services (MD or DO) Office Visits Only |
60% Deductible Applies |
50% Deductible Applies |
| Other Physician Office Services
Includes, but not limited to injections, x-ray/lab and other services. Does not include Durable Medical Equipment, Prosthetics or Orthotic Devices. |
60% Deductible Applies |
50% Deductible Applies |
|
Allied Primary Care Health Professional (Certified Nurse Practitioner, Certified Nurse Midwife, Physician Assistant) Office Visits Only |
60% Deductible Applies |
50% Deductible Applies |
|
Other Allied Office Services
Includes, but not limited to injections, x-ray/lab and other services. Does not include Durable Medical Equipment, Prosthetics or Orthotic Devices. |
60% Deductible Applies |
50% Deductible Applies |
Allied Specialist Office Visits Only*** |
60% Deductible Applies |
50% Deductible Applies |
|
Other Office Services*** |
60% Deductible Applies |
50% Deductible Applies |
| ***When Physical Medicine services are provided, Benefits are limited to 20 visits per calendar year and 3 modalities per visit. The limit applies to visits in the home or at the Allied Specialist's office or facility. Benefits are not provided for Physical Medicine Services provided by Non-Network Providers. Services provided by Non-Network Physical Therapists, Occupational Therapists and/or Chiropractors are not covered. |
||
Other Allied Services |
||
|
|
Network Provider | Non-Network Provider |
| Ambulance Services, Allergy Testing/Injections |
60% Deductible Applies |
50% Deductible Applies |
| Diagnostic Services Facility, Dialysis Treatment, Durable Medical Equipment, Independent Laboratory, Infusion Therapy, Outpatient Cardiac Rehabilitation, Sleep Studies | 60% Deductible Applies |
Not Covered |
| Hospice Care Limited to 6 months per lifetime, subject to Care Management |
60% Deductible Applies |
Not Covered |
| Habilitative Care Limited to 20 Physical Therapy and Occupational Therapy visits, combined, and 20 Speech Therapy visits per calendar year. |
60% Deductible Applies |
Physical Therapy and Occupational Therapy: Not Covered Speech Therapy: 50%, Deductible Applies |
| Physical Medicine - Limited to 20 visits per calendar year and 3 modalities per visit. The limit applies to visits in the home or at the Allied Specialist's office or facility. | 60% Deductible Applies |
Not Covered |
| Prosthetics and Orthotic Devices | 60% Deductible Applies |
60% Deductible Applies |
| Speech Therapy - Limited to 20 visits per calendar year | 60% Deductible Applies |
50% Deductible Applies |
| Therapy Services - Includes chemotherapy, gene therapy, immunotherapy, radiation and respiratory therapy. | 60% Deductible Applies |
Not Covered |
| Mental Health and Substance Use Disorder Services | ||
|
|
Network Provider | Non-Network Provider |
| Inpatient Care | 60% Deductible Applies |
50% Deductible Applies |
| Partial Hospitalization | 60% Deductible Applies |
50% Deductible Applies |
| Hospital Outpatient Visits | 60% Deductible Applies |
50% Deductible Applies |
| Other Outpatient Physician and Allied Professional Services |
60% Deductible Applies |
50% Deductible Applies |
| Physician and Allied Professional Office Visits | 60% Deductible Applies |
50% Deductible Applies |
| Other Services Rendered in Physician and Allied Professional Office | 60% Deductible Applies |
50% Deductible Applies |
| Pediatric Dental and Vision Services | ||
| Pediatric dental and vision benefits are available for members up to age 19. |
||
| Pediatric Dental | ||
| Preventive and Diagnostic Services | 60% Deductible Waived |
60% Deductible Waived |
| Other Dental Services (as defined within the Benefit Plan) | 50% Deductible Waived |
50% Deductible Waived |
| Pediatric Vision | ||
| Routine Eye Exam | 60% Deductible Waived |
Not Covered |
| Eyeglasses - One pair per year, subject to limitations within the Benefit Plan. | 100% up to $150 Deductible Waived |
Not Covered |
This summary of the Benefit Choice 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. All services are subject to Medical Policy and Care Management.
