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1 Deductible, Copays and Dollar Maximums Deductible Fixed Dollar Copays Coinsurance Annual Coinsurance Maximum (ACM) Out of Pocket Maximum - applies to deductibles, copays and coinsurance amounts for all covered services $2,800 per individual/$5,600 per family Enhanced Benefits : CLSSLG : 1400MF, D400, CO20, ONVXF,, AMB25, DME5, ER150, 1040CS, MOPD2O, P&O5, 30RP, UR35, DSRCW, 11/16/ :10:16 am
2 Preventive Services Health Maintenance Exam Annual Gynecological Exam Pap Smear Screening Well-Baby and Child Care Immunizations Prostate Specific Antigen (PSA) Screening Routine Colonoscopy Mammography Screening Voluntary Female Sterilization Breast Pumps (DME guidelines apply.) Maternity Pre-Natal care Physician Office Services PCP Office Visits Online Visits Consulting Specialist Care Enhanced Benefits : CLSSLG : 1400MF, D400, CO20, ONVXF,, AMB25, DME5, ER150, 1040CS, MOPD2O, P&O5, 30RP, UR35, DSRCW,
3 Emergency Medical Care Hospital Emergency Room - Copay waived if admitted Urgent Care Center Ambulance Services Diagnostic Services Laboratory and Pathology Tests Diagnostic Tests and X-rays High Technology Radiology Imaging (MRI, MRA, CAT, PET) Radiation Therapy Maternity Services Provided by a Physician Post-Natal and Non-routine Pre-Natal Care (See Preventive Services section for routine Pre-Natal Care) Delivery and Nursery Care Enhanced Benefits : CLSSLG : 1400MF, D400, CO20, ONVXF,, AMB25, DME5, ER150, 1040CS, MOPD2O, P&O5, 30RP, UR35, DSRCW,
4 Hospital Care General Nursing Care, Hospital Services and Supplies Outpatient Surgery - included all related surgical services and anesthesia - see member certificate for specific surgical copays. Alternatives to Hospital Care Skilled Nursing Care Hospice Care Home Health Care Enhanced Benefits : CLSSLG : 1400MF, D400, CO20, ONVXF,, AMB25, DME5, ER150, 1040CS, MOPD2O, P&O5, 30RP, UR35, DSRCW,
5 Surgical Services Surgery - includes all related surgical services and anesthesia - see member certificate for specific surgical copays. Voluntary Male Sterilization See Preventive Services section for voluntary female sterilization Elective Abortion (One procedure per two year period of membership) Human Organ Transplants Reduction Mammoplasty Male Mastectomy Temporomandibular Joint Syndrome Orthognathic Surgery Weight Reduction Procedures (Limited to one procedure per lifetime) Enhanced Benefits : CLSSLG : 1400MF, D400, CO20, ONVXF,, AMB25, DME5, ER150, 1040CS, MOPD2O, P&O5, 30RP, UR35, DSRCW,
6 Mental Health Care and Substance Use Disorder Treatment Inpatient Mental Health Care Inpatient Substance Use Disorder Outpatient Mental Health Care includes online visits Note: For diagnostic and therapeutic services, the medical benefit applies. Outpatient Substance Use Disorder Autism Spectrum Disorders, Diagnoses and Treatment Applied behavioral analyses (ABA) treatment Outpatient physical therapy, speech therapy and occupational therapy for autism spectrum disorder through age 18. Unlimited visits for PT/OT/ST with autism spectrum disorder diagnosis. Other covered services, including mental health services, for Autism Spectrum Disorder Enhanced Benefits : CLSSLG : 1400MF, D400, CO20, ONVXF,, AMB25, DME5, ER150, 1040CS, MOPD2O, P&O5, 30RP, UR35, DSRCW,
7 Other Services Allergy Testing and Therapy Allergy Injections Chiropractic Spinal Manipulation - when referred Outpatient Physical, Speech and Occupational Therapy Infertility Counseling and Treatment (Excludes In-vitro fertilization) Durable Medical Equipment (DME) Prosthetic and Orthotic Appliances (P&O) Diabetic Supplies Prescription Drugs (max copay $450/prescription) (max copay $600/prescription) Enhanced Benefits : CLSSLG : 1400MF, D400, CO20, ONVXF,, AMB25, DME5, ER150, 1040CS, MOPD2O, P&O5, 30RP, UR35, DSRCW, 11/16/ :10:18 am
8 Mail Order Prescription Drugs Prescription Drug Deductible Hearing Aid Healthy Text291: Blue Living subscribers must complete program requirements within the first 90 days of enrollment or re-enrollment. To qualify for or maintain enhanced benefits, the subscriber needs to complete a health assessment and qualification form during the first 90 days and follow their primary care physician s recommendations for a healthy lifestyle. If a tobacco user, must enroll in the BCN-sponsored tobacco cessation program within 120 days of the start of the plan year. If BMI is greater than or equal to 30, must select and begin participating in a weight management program within 120 days of the start of the plan year. Enhanced Benefits : CLSSLG : 1400MF, D400, CO20, ONVXF,, AMB25, DME5, ER150, 1040CS, MOPD2O, P&O5, 30RP, UR35, DSRCW, 11/16/ :10:18 am
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