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Blue Health Savings Outline of Benefits

Combined Medical and Prescription Drug Deductible

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: $7,500

Family: 2 times the Individual Amount		 Not applicable for services rendered by Out-of-Network Providers
Coinsurance Options 80% or 90% 50%
Deductible Options
Calendar Year Combined Medical and Prescription Drug Deductible Options
Deductible must be met before any
Coinsurance amounts apply. If more than one person is covered, the full family Deductible must be met before Coinsurance amounts apply. If the Family Deductible exceeds the Individual Maximum Out-of-Pocket amount, no one covered family member will contribute more that the Individual Out-of-Pocket limit.		 Individual: $3,900 or $4,750

Family: 2 times the Individual Amount		 Individual: 2 times the Network Amount

Family: 2 times the Non-Network Individual Amount
Health & 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.		 80% or 90%
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. 80% or 90%
Deductible Applies		 Not Covered
Category 2-Generally includes higher-cost generic and many brand-name drugs. 80% or 90%
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. 80% or 90%
Deductible Applies		 Not Covered
Category 4-Generally includes high cost generic drugs, high cost technology drugs and specialty drugs. 80% or 90%
Deductible Applies		 Not Covered
Maintenance Medications (90-day supply)

Must use Community PLUS Maintenance Pharmacies		 80% or 90%
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, Biosimilar Product or lower cost alternative may only be covered if the generic alternative, Interchangeable Biological Product or Biosimilar 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
80% or 90%
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. *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
Coinsurance +10%
Deductible Applies		 Coinsurance -10%
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
Coinsurance +10%
Deductible Applies		 Coinsurance -10%
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 Coinsurance
Deductible Applies		 50%
Deductible Applies
Outpatient Hospital Services Coinsurance
Deductible Applies		 50%
Deductible Applies
Emergency Room Services -
Non-emergent services are subject to the Non-Network Provider Coinsurance amount.
Coinsurance
Deductible Applies
 Coinsurance
Deductible Applies
Newborn Well Baby Care - Exams and routine hospital nursery care of a well newborn. Coinsurance
Deductible Applies		 50%
Deductible Applies
Ambulatory Facility Services
Ambulatory Surgical Facility Services
Coinsurance
Deductible Applies
 50%
Deductible Applies
Physician and Allied Professional Services
Covered Services
 Network Provider Non-Network Provider
Physician and Allied Professional Office Visit Coinsurance Options Primary Care: 80%, 90%
Specialist: 80%, 90%
Deductible Applies		 50%
Deductible Applies
Physician Office Services (MD or DO)
Office Visits Only
Coinsurance
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.
Coinsurance
Deductible Applies
 50%
Deductible Applies
Allied Primary Care Health Professional (Certified Nurse Practitioner, Certified Nurse Midwife, Physician Assistant) Office Visits Only
Coinsurance
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.
Coinsurance
Deductible Applies
 50%
Deductible Applies
Allied Specialist Office Visits Only***
Coinsurance
Deductible Applies
 50%
Deductible Applies
Other Office Services***
Coinsurance
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 Injection/Testing
Coinsurance
Deductible Applies
 50%
Deductible Applies
Diagnostic Services Facility, Dialysis Treatment, Durable Medical Equipment, Independent Laboratory, Infusion Therapy, Outpatient Cardiac Rehabilitation, Sleep Studies
Coinsurance
Deductible Applies
 Not Covered
Hospice Care
Limited to 6 months per lifetime, subject to Care Management
Coinsurance
Deductible Applies
 Not Covered
Habilitative Care
Limited to 20 Physical Therapy and Occupational Therapy visits, combined, and 20 Speech Therapy visits per calendar year.
Coinsurance
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.
Coinsurance
Deductible Applies
 Not Covered
Prosthetics and Orthotic Devices
Coinsurance
Deductible Applies
Coinsurance
Deductible Applies
Speech Therapy - Limited to 20 visits per calendar year
Coinsurance
Deductible Applies
50%
Deductible Applies
Therapy Services - Includes chemotherapy, gene therapy, immunotherapy, radiation and respiratory therapy.
Coinsurance
Deductible Applies
Not Covered
MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES
Network Provider Non-Network Provider
Inpatient Care
Coinsurance
Deductible Applies
50%
Deductible Applies
Partial Hospitalization
Coinsurance
Deductible Applies
50%
Deductible Applies
Hospital Outpatient Visits
Coinsurance
Deductible Applies
50%
Deductible Applies
Other Outpatient Physician and Allied Professional Services
Coinsurance
Deductible Applies
50%
Deductible Applies
Physician and Allied Professional Office Visits
Coinsurance
Deductible Applies
50%
Deductible Applies
Other Services Rendered in Physician and Allied Professional's Office
Coinsurance
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 Coinsurance
Deductible Applies		 Coinsurance
Deductible Applies
Other Dental Services (as defined within the Benefit Plan) 50%
Deductible Applies		 50%
Deductible Applies
Pediatric Vision
Routine Eye Exam Coinsurance
Deductible Applies		 Not Covered
Eyeglasses - One pair per year, subject to limitations within the Benefit Plan. 100% up to $150 after Deductible

 Not Covered

This summary of the Blue Care Group 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.

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