BCBSAZ Individual HMO Portfolio ZCS Plan Attachment Neighborhood Network On Exchange 21016 0118 Suite E
PLAN NETWORK Your Plan Network is the Neighborhood Network. The BCBSAZ provider directory of Neighborhood Network providers is available online at www.azblue.com. If you do not have Internet access, or you have questions about a provider s network participation, please call BCBSAZ Customer Service before you receive services. 1
MEMBER COST-SHARING & OTHER PAYMENTS Member cost-share is waived for services covered under this plan. Pediatric Dental Services: LEAT Processing for Pediatric Dental Services Coverage for restorative (Type II and III) services is subject to Least Expensive Available Treatment (LEAT) processing. BCBSAZ determines whether a restorative service is subject to LEAT processing based upon its LEAT Guidelines, which are available to you upon request. If a restorative service is subject to LEAT processing, the least expensive available treatment for the restorative service is a covered service under this benefit plan (the Covered Restorative Service ). The more expensive available restorative treatment is not a covered service under this benefit plan (the Non-Covered Restorative Service ). The difference between the allowed amount for the Covered Restorative Service and the dentist s billed charges for the Non-Covered Restorative Service is the LEAT Balance Bill. If LEAT processing applies and you choose the Non-Covered Restorative Service, you will pay the LEAT Balance Bill. Predetermination of Benefits for Pediatric Dental Services Your dentist may ask BCBSAZ or its contracted vendor to estimate the benefits that will be available to cover a proposed treatment plan. Upon request, BCBSAZ or its contracted vendor will send a predetermination of benefits to your dentist. Because BCBSAZ or its contracted vendor will require detailed information, including the procedure codes for your proposed treatment, BCBSAZ or its contracted vendor will accept predetermination requests only from dentists. BCBSAZ or its contracted vendor will provide a non-binding estimate of your benefits that would be available under your plan, based on the information available to us at the time the request is submitted. Your claim may process differently from the predetermination of benefits for reasons that include, but are not limited to, whether BCBSAZ or its contracted vendor processes additional claims after the predetermination is issued, whether there are any changes to your eligibility status between the date of the predetermination of benefits and the date of service, whether your dentist submits a claim with different procedures or codes than were submitted with the predetermination request, and whether coordination of benefits applies. You may want to ask your dentist to submit a predetermination request if you are considering an extensive course of treatment. If least expensive available treatment (LEAT) analysis would apply to your proposed treatment, the predetermination will provide an estimate of your cost-share based on the LEAT. You will be responsible for any balance bill. However, BCBSAZ or its contracted vendor does not require predeterminations for any services covered under this plan. Predeterminations are not the same as precertifications, which are required prior to receipt of certain covered medical services. Your dentist may call BCBSAZ or its contracted vendor at the Customer Service number listed on your ID card for information on how to request a predetermination of benefits. 2
COST-SHARE TABLE Benefit Cost-Share 1. AMBULANCE 2. BEHAVIORAL AND MENTAL HEALTH (Outpatient Facility and Professional Services) 3. BEHAVIORAL AND Facility and Professional Services: MENTAL HEALTH (Inpatient) 4. BEHAVIORAL THERAPY FOR THE TREATMENT OF AUTISM SPECTRUM DISORDER 5. CATARACT SURGERY & KERATOCONUS 6. CHIROPRACTIC 7. CHRONIC DISEASE EDUCATION AND TRAINING (Diabetes and Asthma Education and Training; Nutritional Counseling and Training) 8. CLINICAL TRIALS 9. DENTAL BENEFIT MEDICAL 10. DURABLE MEDICAL EQUIPMENT (DME), MEDICAL SUPPLIES AND PROSTHETIC APPLIANCES AND ORTHOTICS 11. EMERGENCY Emergency Room: (PROFESSIONAL AND FACILITY CHARGES) Admission to the Hospital From the Emergency Room: Your cost-share is waived. 12. EOSINOPHILIC Your cost-share is waived for amino-acid based formula ( Formula ). GASTROINTESTINAL DISORDER 13. FAMILY PLANNING Implanted Devices: (CONTRACEPTIVES AND STERILIZATION) Sterilization Procedures: Hormonal Contraceptive Methods: Your cost-share is waived for oral contraceptives, patches, rings and contraceptive injections. See the Physician Services and Pharmacy Benefit sections for benefits. Emergency Contraception: Your cost-share is waived for FDAapproved over-the-counter emergency contraception when prescribed by a physician or other provider. See the Physician Services section for benefits. Barrier Contraceptive Methods: Your cost-share is waived for diaphragms, cervical caps, cervical shields, condoms, sponges and spermicides. See the Physician Services and the Pharmacy Benefit sections for benefits. 14. HEARING 15. HOME HEALTH 16. HOSPICE 3
Benefit 17. INPATIENT AND OUTPATIENT DETOXIFICATION 18. INPATIENT HOSPITAL Cost-Share 19. INPATIENT REHABILITATION EXTENDED ACTIVE REHABILITATION (EAR) AND SKILLED NURSING FACILITY (SNF) 20. LONG-TERM ACUTE CARE (INPATIENT) 21. MATERNITY Inpatient and Outpatient Services: 22. MEDICAL FOODS FOR INHERITED METABOLIC DISORDERS 23. NEUROPSYCHOLOGICAL AND COGNITIVE TESTING 24. OUTPATIENT Diagnostic Laboratory Services: Radiology Services: 25. PHYSICAL THERAPY (PT) - OCCUPATIONAL THERAPY (OT) - SPEECH THERAPY (ST) COGNITIVE THERAPY (CT) - CARDIAC AND PULMONARY REHABILITATION 26. PHYSICAL THERAPY (PT) - OCCUPATIONAL THERAPY (OT) - SPEECH THERAPY (ST) COGNITIVE THERAPY (CT) - CARDIAC AND PULMONARY HABILITATION Outpatient Facility Services (Including Outpatient Surgery): Your costshare is waived. Sleep Studies: Medications Administered in an Outpatient Facility: Your cost-share is waived. 27. PHYSICIAN 28. POST-MASTECTOMY 29. PRESCRIPTION MEDICATIONS FOR THE TREATMENT OF CANCER 4
Benefit 30. PHARMACY BENEFIT If you are currently obtaining a covered Specialty Medication from a Specialty Pharmacy, you can receive that medication from a network retail pharmacy. Please call the Pharmacy Benefit Customer Service number on your ID card if you need assistance with this issue. Cost-Share Medications Obtained From Retail/Mail Order Pharmacies: Your costshare is waived. Specialty Medications: For certain Cancer Treatment Medications, as determined by BCBSAZ, you will receive a 15-day supply the first time you receive the medication. You will be able to refill the medication every 15 days for each refill during your first three months of treatment with the medication. If you experience side effects from the medication during the three-month period, your prescribing provider may change your medication. If you tolerate the medication, you will be able to refill the Cancer Treatment Medication for up to 30 days after three months of treatment. If you are currently obtaining a covered medication from the network mail order pharmacy, you can receive that medication from a network retail pharmacy. Please contact the Pharmacy Benefit Customer Service number on your ID card if you need assistance with this issue. If you are taking two or more prescription medications for a chronic condition, you may request early or short refills of eligible covered medications by contacting the Pharmacy Benefit Customer Service number on your ID card and requesting enrollment in the BCBSAZ Medication Synchronization program. If you are enrolled in the BCBSAZ Medication Synchronization program, your cost-share for eligible covered medications will be adjusted for any early or short refills of those medications. 31. PREVENTIVE 32. RECONSTRUCTIVE SURGERY AND 33. TO DIAGNOSE INFERTILITY 34. TELEMEDICINE 5
Benefit 35. TRANSPLANTATIONS - ORGAN - TISSUE - BONE MARROW TRANSPLANTATIONS AND STEM CELL PROCEDURES Cost-Share If both a donor and a transplantation recipient are covered by a BCBSAZ plan or a plan administered by BCBSAZ, the transplantation recipient pays the cost-share related to the transplantation. 36. TRANSPLANTATION TRAVEL AND LODGING 37. URGENT CARE 38. PEDIATRIC DENTAL TYPE I 39. PEDIATRIC DENTAL TYPE II 40. PEDIATRIC DENTAL TYPE III 41. PEDIATRIC DENTAL TYPE IV 42. PEDIATRIC VISION EXAMS (ROUTINE) All claims for Type II services are subject to analysis for the least expensive available treatment (LEAT) processing. If you choose a Non- Covered Restorative Service, you pay the LEAT Balance Bill. All claims for Type III services are subject to analysis for the least expensive available treatment (LEAT) processing. If you choose a Non- Covered Restorative Service, you pay the LEAT Balance Bill. 43. PEDIATRIC CONTACT LENS FIT AND FOLLOW UP 44. PEDIATRIC EYEWEAR 45. PEDIATRIC LOW VISION EVALUATION AND FOLLOW UP 46. PEDIATRIC LOW VISION HARDWARE 6
NONDISCRIMINATION STATEMENT Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call (602) 864-4884 for Spanish and (877)475-4799 for all other languages and other aids and services. If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: BCBSAZ s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ 85002-3466, (602) 864-2288, TTY/TDD (602) 864-4823, crc@azblue.com. You can file a grievance in person or by mail or email. If you need help filing a grievance BCBSAZ s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1 800 368 1019, 800 537 7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 7
MULTI-LANGUAGE INTERPRETER 8