BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to age 26 Filing Limit 1 year from date of service Mailing Address & PPO Company. Remit claims to: Blue Cross Blue Shield of Arizona PPO: Blue Cross Blue Shield of Arizona PHYSICIAN CLAIMS: All PPO claims should be submitted electronically to Blue Cross Blue Shield of Arizona with submitter ID 53589. Any claim that cannot be submitted electronically should be mailed to Gilsbar at P.O. Box 2947, Covington, LA 70434. BCBS (800) 232 2345 Blue Cross Blue Shield of Arizona HOSPITAL FACILITY CLAIMS Mail all PPO claims to: Blue Cross Blue Shield of Arizona P.O. Box 2924, Phoenix, AZ, 85062 2924. BCBSAZ (800) 232 2345 ext. 4885. Group number for BCBS is RBT001. Non PPO: Mail claims to: Gilsbar, Inc. P.O. Box 2947, Covington, LA 70434 (800) 445 7227 Pre Existing Does not apply Utilization Review: MedCom Management 800 643 4416 Pre notification within 72 hours of admission. All inpatient admissions, MRIs, DME over $1,000, and Outpatient Surgery (except in office). PENALTY: Additional $250 per occurrence ANNUAL MAXIMUM BENEFIT DEDUCTIBLE, PER CALENDAR YEAR Unlimited Deductibles are combined, that is, expenses applied toward the satisfaction of the PPO will be applied toward satisfaction of the Non PPO, and vice versa. Per Participant $500 $1,250 Per Family $1,000 $2,500 MAXIMUM OUT OF POCKET EXPENSES, PER CALENDAR YEAR Out of Pocket expense amounts are combined, that is, expenses applied toward the satisfaction of the PPO out of pocket amount will be applied toward satisfaction of the Non PPO out of pocket amount, and vice versa. Per Participant $1,500 $26,250 Per Family $3,000 $52,500 NOTE: The following charges do not apply toward the out of pocket expense amount and are never paid at 100%: N/A HEALTH BENEFITS: COPAYMENTS AND BENEFIT PERCENTAGES Accident Benefit Common Accident Deductible applies; refer to plan document for details Acupuncture Ambulance (Air Ambulance limited to $20,000 paid per trip) Bariatric Surgery GILSBARDM #1660216 v92 All_Other_Districts_Plan_II_eff_07012004_to_Present Page 1 of 6
unless Medically Necessary. plan document for further limitations & exclusions Behavioral/Mental Health and Substance Use Disorders Inpatient Includes Residential Treatment Behavioral/Mental Health and Substance Use Disorders Outpatient Includes Partial Hospitalization Blood Blood and blood derivatives that are not donated or replaced are covered. Chemotherapy & Radiation Therapy $40 copay then Inpatient Outpatient Clinical Trials (as defined by this Plan for cancer or other lifethreatening diseases or conditions) Includes coverage for routine patient costs associated with participation in approved Clinical Trials only. If one or more PPO providers are participating in a Clinical Trial, the Plan may require that the qualified individual participate in the Clinical Trial with the PPO provider. The Plan will cover Non PPO providers outside the state in which the qualified individual resides only if there is not a PPO provider conducting the same trial in state. Chiropractic Treatment Dental Impacted Wisdom Teeth Diabetes Self management Training Diagnostic Testing (Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) MRI must be precertified Diagnostic Testing (X ray, lab) Inpatient Diagnostic Testing (X ray, lab ) Outpatient Hospital All outpatient drug testing will be subject to a medical necessity review Diagnostic Testing (X ray, lab) Stand Alone Facility All outpatient drug testing will be subject to a medical necessity review Diagnostic Testing (X ray, lab) Office All outpatient drug testing will be subject to a medical necessity review Durable Medical Equipment (Expenses for equipment over $1,000 must be precertified) Emergency Services in an Emergency Room Extended /Skilled Nursing Facility (60 days Calendar Year maximum) Foot Conditions Physicians' services in connection with corns, calluses or toenails are excluded, unless the charges are for the partial or complete removal Non Surgical Treatment of the Spine Covered under Separate Dental plan Covered under Medical Plan only. Surgeon Benefit (facility will follow facility ) GILSBARDM #1660216 v92 All_Other_Districts_Plan_II_eff_07012004_to_Present Page 2 of 6
of the nail roots. Routine foot care and foot orthotics are not covered Gastric Bypass Hearing Aids Hearing Screening Home Health (60 visits Calendar Year maximum) Hospice Bariatric Surgery Bereavement Counseling by Hospice provider. For other bereavement counseling services refer to Behavioral/Mental Health and Substance Use Disorders Outpatient Hospital / Facility Inpatient Room and Board is limited to the semiprivate room rate, or if the Hospital has private rooms only, 90% of the lowest private room rate. ICU will be billed at three times the semi private room rate Hospital / Facility Outpatient Precertification required for outpatient surgery Infertility/Sterility Maternity Prenatal as required by federal law $40 copay then See Preventive See Preventive Other Eligible Charges Maternity related expenses for dependent Children are not covered, except for complications and as required by law for prenatal care. Newborn (routine inpatient) Non Surgical Treatment of the Spine ($1,500 Calendar Year maximum) (OV & X ray not included in the Calendar Year maximum) Obesity unless Medically Necessary for Morbid Obesity plan document for further limitations & exclusions Organ Transplants Provider should notify Customer Contact Center prior to starting any transplant services, including initial evaluation. Case Management is strongly suggested. plan document for further limitations & exclusions. Orthotics / Prosthetics Physician Services Inpatient Visits Physician Services Inpatient Surgeon Physician Services Outpatient Visits (services other than in a Physician's office) Physician Services Outpatient Surgeon (services other than in a Physician's office) Physician Services Office Visits GILSBARDM #1660216 v92 All_Other_Districts_Plan_II_eff_07012004_to_Present Page 3 of 6
Copay is per day and applies only to office visit charge, X ray & lab services, injections, allergy injections, allergy treatment and minor office surgery; Allergy treatment copay is waived if there is no office visit charge Deductible All other eligible expenses rendered in the physician s office not covered under copay. Physician Services In office Surgeon Preadmission Testing Prescription Drugs Inpatient Prescription Drugs Outpatient Preventive Benefit Preventive includes the following: routine physical exam, X ray & lab, pap smear, gynecological exam, prostate exam and mammograms (see plan document for age ranges). Physician Services: Office Visits 80%, no Physician Services: Office Visits 60%, no Hospital / Facility Inpatient Prescription Drug Benefits schedule and section Breast pumps are limited to one per calendar year Services are also covered as recommended by the United States Preventive Services Task Force (USPSTF) and immunizations will be covered as recommended by the Centers for Disease Control (CDC). All services are limited to no more than once annually or as recommended by the USPSTF Private Duty Nursing ($10,000 Lifetime maximum) Services performed by a registered Nurse, licensed vocational Nurse or a licensed practical Nurse when Medically Necessary (noncustodial) and provided on an Inpatient basis because the Hospital s Intensive Unit is filled or the Hospital has no Intensive Unit. NOTE: Outpatient nursing care is covered only when part of a home health care plan (see Home Health ). Outpatient private duty nursing care on a 24 hour shift basis is not covered. Rehabilitation Services Inpatient (Cardiac Rehab, Occupational, Physical, and Speech Therapies) Provider must send letter of medical necessity and all applicable notes Cardiac rehab therapies limited to phase I & II Occupational, Physical, & Speech Therapy 60 days Calendar Year maximum combined for all. Rehabilitation Services Outpatient (Cardiac Rehab, Occupational, Physical, and Speech Therapies) Provider must send letter of medical necessity and all applicable notes Cardiac rehab therapies limited to phase I & II Sleep Disorder Covered only if medically necessary. Sleep Study 100%, no GILSBARDM #1660216 v92 All_Other_Districts_Plan_II_eff_07012004_to_Present Page 4 of 6
Other eligible expenses applicable service for applicable service for Sterilization (Vasectomy) Female Sterilization as required by federal law Temporomandibular Joint Syndrome ($1,000 Calendar Year maximum) Urgent Facility (includes all covered charges billed by facility) Vision Exam (Limited to $125 and 1 exam per 12 month period; $125 Calendar Year maximum does not apply to enrollees under age 19) Materials (includes frames, lenses and contact lenses) (Limited to $300 maximum benefit per 12 month period Vision Therapy Deductible See Preventive Deductible See Preventive $40 copay then 100%, no 100%, no 100%, no 100%, no GILSBARDM #1660216 v92 All_Other_Districts_Plan_II_eff_07012004_to_Present Page 5 of 6
PRESCRIPTION DRUG CARD OPTION Partners Rx: 800 424 5828 www.magellanrx.com RxBIN: 017449 RxPCN: 6792000 RxGRP: PRXBIC Paid by invoice. Non Partners Rx except injectables (excluding insulin) Prescription Drug Card Options Copayment Benefit Percentage Retail Pharmacy Option (30 day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the physician Over the Counter drug (Physician s prescription required) $0 100% $0 100% Generic drug $5 100% Preferred Brand Name drug $40 100% Non Preferred Brand Name drug $55 100% Specialty drugs 80% to a maximum of $150 Mail Order Option (90 day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the physician $0 100% Generic drug $10 100% Preferred Brand Name drug $80 100% Non Preferred Brand Name drug $110 100% Specialty drugs 80% to a maximum of $300 GILSBARDM #1660216 v92 All_Other_Districts_Plan_II_eff_07012004_to_Present Page 6 of 6