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(x) Tj
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(Your group has determined that you work on average 30 or more hours per week \(including vacation) Tj
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(x) Tj
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(x) Tj
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(x) Tj
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(Your eligible dependents are:) Tj
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(x) Tj
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(x) Tj
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(federal income tax return.) Tj
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(period.) Tj
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(Coverage will be effective no later than the first day of the first calendar month beginning after the date) Tj
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(the plan receives the request for special enrollment.) Tj
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(number of hours of employment, failure of your employer to offer minimum essential coverage to you, and) Tj
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(misrepresentation of a material fact.) Tj
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ET
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ET
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ET
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(of Medicare's coverage, depending upon, among other things, the size of your group, whether your group) Tj
ET
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ET
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ET
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/F2 10 Tf
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(please read the section entitled) Tj
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(benefits available to employees under age 65.) Tj
ET
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/F2 10 Tf
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ET
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(primary to Medicare.) Tj
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(If you are enrolled in Medicare, Medicare will pay for Medicare eligible) Tj
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(expenses, if any, not paid by the plan.) Tj
ET
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(If both you and your spouse are over age 65, you may elect to enroll in Original Medicare or a) Tj
ET
BT
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(Medicare Advantage plan and/or a Medicare Part D prescription drug plan and disenroll) Tj
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(completely from the plan.) Tj
ET
BT
/F2 10 Tf
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(This means that you will have no benefits under the plan.) Tj
ET
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ET
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Q
q
Q
Q

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(9) Tj
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Q
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0 0 0 rg
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(the heading) Tj
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(employees during the previous calendar year.) Tj
ET
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ET
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(of your Medicare eligibility \(regardless of the size of the group\).) Tj
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ET
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ET
BT
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(drug benefits are not at least as good as standard Medicare Part D prescription drug coverage,) Tj
ET
BT
/F2 10 Tf
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(you should enroll in Part D of Medicare when you become eligible for Medicare.) Tj
ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
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(tell you whether the plan's prescription drug benefits are at least as good as Medicare Part D.) Tj
ET
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/F2 10 Tf
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(If you have any questions about coordination of your coverage with Medicare, please contact your group) Tj
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(for further information.) Tj
ET
BT
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(You may also find additional information about Medicare at) Tj
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(www.medicare.gov) Tj
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(.) Tj
ET
BT
/F6 12 Tf
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(Termination of Coverage) Tj
ET
BT
/F2 10 Tf
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(Plan coverage ends as a result of the first to occur of the following \(generally, coverage will continue to) Tj
ET
BT
/F2 10 Tf
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(the end of the month in which the event occurs\):) Tj
ET
BT
/F411 10 Tf
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(x) Tj
ET
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/F2 10 Tf
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(The date on which the employee fails to satisfy the conditions for eligibility to participate in the plan,) Tj
ET
BT
/F2 10 Tf
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(such as termination of employment or reduction in hours \(except during vacation or as otherwise) Tj
ET
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( rules below\);) Tj
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/F411 10 Tf
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(x) Tj
ET
BT
/F2 10 Tf
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(For spouses, the date of divorce or other termination of marriage;) Tj
ET
BT
/F411 10 Tf
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(x) Tj
ET
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/F2 10 Tf
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(For children, the date a child ceases to be a dependent;) Tj
ET
BT
/F411 10 Tf
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(x) Tj
ET
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/F2 10 Tf
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(For the employee and his or her dependents, the date of the employee's death;) Tj
ET
BT
/F411 10 Tf
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(x) Tj
ET
BT
/F2 10 Tf
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ET
BT
/F411 10 Tf
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(x) Tj
ET
BT
/F2 10 Tf
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(Upon discovery of fraud or intentional misrepresentation of a material fact by you.) Tj
ET
BT
/F2 10 Tf
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(In all cases, the termination occurs automatically and without notice.) Tj
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/F2 10 Tf
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(All the dates of termination assume) Tj
ET
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/F2 10 Tf
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(that payment for coverage for you and your dependents in the proper amount has been made to that) Tj
ET
BT
/F2 10 Tf
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(date.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 27.8 168.42 Tm
(If it has not, termination will occur back to the date for which coverage was last paid.) Tj
ET
BT
/F2 10 Tf
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(Our contract with your group \(and your coverage as administered by us\) will end as a result of the first to) Tj
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(occur of the following \(generally, coverage will continue to the end of the month in which the event) Tj
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(occurs\):) Tj
ET
BT
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(x) Tj
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(x) Tj
ET
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/F2 10 Tf
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ET
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(x) Tj
ET
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(When none of your group's members still live, reside or work in Alabama; or,) Tj
ET
BT
/F411 10 Tf
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(x) Tj
ET
BT
/F2 10 Tf
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(On 30-days advance written notice from your group to us.) Tj
ET
BT
/F2 10 Tf
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(In all cases except the last item above, the termination occurs automatically and without notice.) Tj
ET
BT
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(All the) Tj
ET
BT
/F2 10 Tf
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(dates of termination assume that payment for coverage for you and all other employees in the proper) Tj
ET
Q
q
Q
Q

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(amount has been made to that date.) Tj
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(If it has not, termination will occur back to the date for which) Tj
ET
BT
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ET
BT
/F6 12 Tf
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ET
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/F2 10 Tf
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ET
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(coverage under the plan during an FMLA leave, provided that you continue to pay your premiums.) Tj
ET
BT
/F2 10 Tf
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(In) Tj
ET
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/F2 10 Tf
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(general, the FMLA applies to employers who employ 50 or more employees.) Tj
ET
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BT
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ET
BT
/F2 10 Tf
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(You may also continue your coverage under the plan for up to 30 days during an employer-approved) Tj
ET
BT
/F2 10 Tf
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(leave of absence, including sick leave.) Tj
ET
BT
/F2 10 Tf
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(Contact your group to determine whether such leaves of absence) Tj
ET
BT
/F2 10 Tf
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(are offered.) Tj
ET
BT
/F2 10 Tf
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(If your leave of absence also qualifies as FMLA leave, your 30-day leave time runs) Tj
ET
BT
/F2 10 Tf
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(concurrently with your FMLA leave.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 161.73 554.16 Tm
(This means that you will not be permitted to continue coverage) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 542.66 Tm
(during your 30-day leave time in addition to your FMLA leave.) Tj
ET
BT
/F2 10 Tf
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(If you are on military leave covered by the Uniformed Services Employment and Reemployment Rights) Tj
ET
BT
/F2 10 Tf
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(Act of 1994, you should see your group for information about your rights to continue coverage under the) Tj
ET
BT
/F2 10 Tf
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(plan.) Tj
ET
BT
/F6 18 Tf
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(COST SHARING) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.375 439.53 Tm
(Calendar Year Deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 272.89 439.53 Tm
($200) Tj
ET
BT
/F2 8 Tf
1 0 0 1 304.03 439.53 Tm
( individual) Tj
ET
BT
/F2 8 Tf
1 0 0 1 283.13 425.95 Tm
(\($600 family\)) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.375 411.62 Tm
(Calendar Year Out-of-Pocket Maximum) Tj
ET
BT
/F2 8 Tf
1 0 0 1 269.56 411.62 Tm
($1,000) Tj
ET
BT
/F2 8 Tf
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( individual) Tj
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1 w
[] 0 d
0.75 w
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1 w
[] 0 d
0.75 w
[] 0 d
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1 w
[] 0 d
0.75 w
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1 w
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1 w
[] 0 d
BT
/F6 12 Tf
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(Calendar Year Deductible) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 364.68 Tm
(The calendar year deductible is specified in the table above.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 271.28 364.68 Tm
(Other parts of this booklet will tell you when) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 353.18 Tm
(benefits are subject to the calendar year deductible.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 234.59 353.18 Tm
(The calendar year deductible is the amount you or) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 341.68 Tm
(your family must pay for some medical expenses covered by the plan before your healthcare benefits) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 330.18 Tm
(begin.) Tj
ET
BT
/F411 10 Tf
1 0 0 1 0 311.68 Tm
(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 311.68 Tm
(The individual calendar year deductible must be satisfied on a per member per calendar year basis,) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 300.18 Tm
(subject to the family calendar year deductible maximum.) Tj
ET
BT
/F411 10 Tf
1 0 0 1 0 281.68 Tm
(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 281.68 Tm
(The family calendar year deductible is an aggregate dollar amount.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 319.28 281.68 Tm
(This means that all amounts) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 270.18 Tm
(applied toward the individual calendar year deductible will count toward the family calendar year) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 258.69 Tm
(deductible amount.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 108.06 258.69 Tm
(Once the family calendar year deductible is met, no further family members must) Tj
ET
BT
/F2 10 Tf
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(satisfy the individual calendar year deductible.) Tj
ET
BT
/F411 10 Tf
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(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 228.69 Tm
(When covered charges are applied towards the deductible for services rendered in October,) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 217.19 Tm
(November, or December, we will credit those covered charges towards the calendar year deductible) Tj
ET
BT
/F2 10 Tf
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(for the following year.) Tj
ET
BT
/F411 10 Tf
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(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 187.19 Tm
(Only one individual calendar year deductible is required when two or more family members have) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 175.69 Tm
(expenses resulting from injuries received in one accident.) Tj
ET
BT
/F411 10 Tf
1 0 0 1 0 157.19 Tm
(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 157.19 Tm
(In all cases, the deductible will be applied to claims in the order in which they are processed) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 145.69 Tm
(regardless of the order in which they are received.) Tj
ET
BT
/F6 12 Tf
1 0 0 1 0 120.38 Tm
(Calendar Year Out-of-Pocket Maximum) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 100.39 Tm
(The calendar year out-of-pocket maximum is specified in the table above.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 330.17 100.39 Tm
(The calendar year out-of-) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 88.89 Tm
(pocket maximum generally applies to services or supplies that are subject to the calendar year) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 77.39 Tm
(deductible.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 53.93 77.39 Tm
(There may be exceptions to this, depending upon specifications from your group.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 417.47 77.39 Tm
(You may) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 65.89 Tm
(also call Customer Service if you have questions about payments that count towards the calendar year) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 54.4 Tm
(out-of-pocket maximum.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 112.81 54.4 Tm
(Once the maximum has been reached, covered expenses of the type that count) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 42.9 Tm
(towards the maximum will be paid at 100% of the allowed amount for the remainder of the calendar year.) Tj
ET
Q
q
Q
Q

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/F2 10 Tf
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(For institutional and professional claims, you should) Tj
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/F2 10 Tf
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(complete a Blue Cross Blue Shield Global� Core claim form and send the claim form with the) Tj
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(processing. Following the instructions on the claim form will help ensure timely processing of your) Tj
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(claim.) Tj
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(The claim form is available from us, the service center or online at) Tj
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(.) Tj
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(call the service center at 1-800-810-BLUE \(2583\) or call collect at 1-804-673-1177, 24 hours a) Tj
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(day, seven days a week.) Tj
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(MEDICAL NECESSITY AND PRECERTIFICATION) Tj
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(The) Tj
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( plan will only pay for care that is medically necessary and not investigational, as determined by us.) Tj
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(The definitions of medical necessity and investigational are found in the) Tj
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(Definitions) Tj
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( section of this booklet.) Tj
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(In some cases described below, the plan requires that you or your treating provider precertify the medical) Tj
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(necessity of your care.) Tj
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/F2 10 Tf
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(Please note that precertification relates only to the medical necessity of care; it) Tj
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(does not mean that your care will be covered under the plan.) Tj
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/F2 10 Tf
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(Precertification also does not mean that we) Tj
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/F2 10 Tf
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(have been paid all monies necessary for coverage to be in force on the date that services or supplies are) Tj
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(rendered.) Tj
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/F2 10 Tf
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(In some cases, your provider will initiate the precertification process for you.) Tj
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/F2 10 Tf
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(You should be sure to check) Tj
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(with your provider to confirm whether precertification has been obtained.) Tj
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(It is your responsibility to) Tj
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(x) Tj
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(at) Tj
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(This list will be updated no more than twice a calendar year.) Tj
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(You should) Tj
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(x) Tj
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/F2 10 Tf
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(Certain advanced imaging \(such as, for example, MRA, MRI, CT, CTA and PET\);) Tj
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/F2 10 Tf
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(For precertification, call 1-866-803-8002 \(toll-free\).) Tj
ET
BT
/F6 10 Tf
1 0 0 1 0 357.17 Tm
(If precertification is not obtained, no benefits will be payable under the plan for the services.) Tj
ET
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/F411 10 Tf
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(x) Tj
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(For precertification, call 1-800-548-9859 \(toll-free\).) Tj
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(x) Tj
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/F2 10 Tf
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/F2 10 Tf
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/F2 10 Tf
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/F6 10 Tf
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(x) Tj
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(For precertification, call 1-800-248-2342 \(toll-free\).) Tj
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/F6 10 Tf
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(If precertification is not obtained, no benefits will be payable under the plan for the services.) Tj
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(x) Tj
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/F6 10 Tf
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(x) Tj
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(.) Tj
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/F2 10 Tf
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(This list will be updated monthly.) Tj
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(Provider-administered drugs are drugs that must typically be administered or directly supervised by a) Tj
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(For precertification, call the Customer Service Department number on the back of your ID card.) Tj
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ET
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(administered drug.) Tj
ET
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ET
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(Precertification \(also sometimes referred to as prior authorization\) is required for certain prescription) Tj
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(.) Tj
ET
BT
/F2 10 Tf
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(This list will be updated quarterly.) Tj
ET
BT
/F2 10 Tf
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(For precertification, call the Customer Service Department number on the back of your ID card.) Tj
ET
BT
/F6 10 Tf
1 0 0 1 0 272.12 Tm
(If precertification is not obtained, no benefits will be payable under the plan for the prescription) Tj
ET
BT
/F6 10 Tf
1 0 0 1 0 260.62 Tm
(drug.) Tj
ET
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/F6 18 Tf
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(Attention:) Tj
ET
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/F6 10 Tf
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(Mental Health Disorders and substance abuse Benefits) Tj
ET
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/F2 10 Tf
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(Except as described in) Tj
ET
BT
/F6 10 Tf
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(Expanded Psychiatric Services \(EPS\) for Mental) Tj
ET
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/F6 10 Tf
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(Health Disorders and Substance Abuse) Tj
ET
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/F2 10 Tf
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( later in this section, benefit levels for) Tj
ET
BT
/F2 10 Tf
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(most mental health disorders and substance abuse are not separately stated.) Tj
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/F2 10 Tf
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(Please refer to the appropriate subsections below that relate to the services or) Tj
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/F2 10 Tf
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(supplies you receive, such as) Tj
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(Inpatient Hospital Benefits) Tj
ET
BT
/F2 10 Tf
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(,) Tj
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(Outpatient Hospital) Tj
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(Benefits) Tj
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(Attention:) Tj
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/F2 10 Tf
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(If you receive out-of-network physician benefits \(such as out-of-) Tj
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(network laboratory services\) for a medical emergency or accidental injury in the) Tj
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(emergency room of a hospital, those services will also be paid at the applicable) Tj
ET
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/F2 10 Tf
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/F2 10 Tf
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ET
BT
/F2 10 Tf
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BT
/F2 10 Tf
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/F2 10 Tf
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(IN-NETWORK) Tj
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(the first 365 days) Tj
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(the calendar year deductible) Tj
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ET
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/F2 8 Tf
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(substance abuse admissions will be the) Tj
ET
BT
/F2 8 Tf
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(same as the benefits shown above for) Tj
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/F2 8 Tf
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(the first 365 days) Tj
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306.4 285.25 l
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(Attention:) Tj
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(If you receive inpatient hospital services in an out-of-network hospital) Tj
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(x) Tj
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(x) Tj
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(x) Tj
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(x) Tj
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/F2 10 Tf
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/F411 10 Tf
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(x) Tj
ET
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/F2 10 Tf
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ET
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/F411 10 Tf
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(x) Tj
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/F2 10 Tf
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ET
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/F2 10 Tf
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(x) Tj
ET
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/F2 10 Tf
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(x) Tj
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ET
BT
/F411 10 Tf
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(x) Tj
ET
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/F2 10 Tf
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(x) Tj
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/F2 10 Tf
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(x) Tj
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/F2 10 Tf
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/F2 10 Tf
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/F2 10 Tf
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(Precertification is required for certain outpatient hospital benefits.) Tj
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(You) Tj
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/F2 10 Tf
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1 0 0 1 311.88 327.11 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
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(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
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(Emergency room � medical emergency) Tj
ET
BT
/F2 8 Tf
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(100% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
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(a $100 outpatient facility copayment) Tj
ET
BT
/F2 8 Tf
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(100% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
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(a $100 outpatient facility copayment) Tj
ET
BT
/F2 8 Tf
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(Mental health disorders and substance) Tj
ET
BT
/F2 8 Tf
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(abuse services: 100% of the allowed) Tj
ET
BT
/F2 8 Tf
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(amount, subject to a $100 outpatient) Tj
ET
BT
/F2 8 Tf
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(facility copayment) Tj
ET
BT
/F2 8 Tf
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(Emergency room � accident) Tj
ET
BT
/F2 8 Tf
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(If you have a medical emergency as) Tj
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(defined by the plan after 72 hours of an) Tj
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BT
/F2 8 Tf
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(accident, refer to "Emergency room -) Tj
ET
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/F2 8 Tf
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(medical emergency" above) Tj
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(100% of the allowed amount, no) Tj
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(deductible or copayment) Tj
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(100% of the allowed amount, no) Tj
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/F2 8 Tf
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(accident; after 72 hours 80% of the) Tj
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/F2 8 Tf
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(allowed amount, subject to the calendar) Tj
ET
BT
/F2 8 Tf
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(year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.88 166.5 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
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(the calendar year deductible when) Tj
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(services are rendered after 72 hours of) Tj
ET
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(the accident and not a medical) Tj
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(Outpatient diagnostic lab, X-ray, and) Tj
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/F2 8 Tf
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(pathology) Tj
ET
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/F2 8 Tf
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(100% of the allowed amount, no) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.88 99.77 Tm
(deductible or copayment) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.88 110.35 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.88 99.77 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.125 85.94 Tm
(Outpatient dialysis, IV therapy,) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.125 75.36 Tm
(chemotherapy, and radiation therapy) Tj
ET
BT
/F2 8 Tf
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(100% of the allowed amount, no) Tj
ET
BT
/F2 8 Tf
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(deductible or copayment) Tj
ET
BT
/F2 8 Tf
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(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
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(the calendar year deductible) Tj
ET
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BT
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(emergency room visit when the patient�s) Tj
ET
BT
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ET
BT
/F2 8 Tf
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(a medical emergency \(including any lab) Tj
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BT
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(and X-ray exams and other diagnostic) Tj
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BT
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(tests associated with the emergency) Tj
ET
BT
/F2 8 Tf
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(room fee\)) Tj
ET
BT
/F2 8 Tf
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(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
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(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.88 668.31 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.88 657.73 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
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(Outpatient hospital services or supplies) Tj
ET
BT
/F2 8 Tf
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(not listed above and not listed in the) Tj
ET
BT
/F2 8 Tf
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(section of this booklet called) Tj
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ET
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121.87 568.71 l
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1 w
[] 0 d
BT
/F2 8 Tf
1 0 0 1 -0.125 559.27 Tm
(Covered Services) Tj
ET
0.586 w
[] 0 d
0.167 558.13 m
62.72 558.13 l
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1 w
[] 0 d
0 0 0 rg
BT
/F2 8 Tf
1 0 0 1 155.88 591.01 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
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(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.88 591.01 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.88 580.43 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.125 545.44 Tm
(Intensive outpatient services and partial) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.125 534.86 Tm
(hospitalization for mental health) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.125 524.28 Tm
(disorders and substance abuse) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.88 545.44 Tm
(100% of the allowed amount, no) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.88 534.86 Tm
(deductible or copayment) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.88 545.44 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.88 534.86 Tm
(the calendar year deductible) Tj
ET
0.25 w
[] 0 d
0 0 0 RG
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-5.53 520.94 l
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1 w
[] 0 d
0.25 w
[] 0 d
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150.48 520.94 l
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1 w
[] 0 d
0.25 w
[] 0 d
306.48 708.25 m
306.48 520.94 l
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1 w
[] 0 d
0.25 w
[] 0 d
462.48 708.25 m
462.48 520.94 l
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1 w
[] 0 d
0.25 w
[] 0 d
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462.47 708.38 l
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1 w
[] 0 d
0.25 w
[] 0 d
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462.22 678.68 l
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1 w
[] 0 d
0.25 w
[] 0 d
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462.22 601.37 l
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1 w
[] 0 d
0.25 w
[] 0 d
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462.22 555.81 l
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1 w
[] 0 d
0.25 w
[] 0 d
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462.47 520.82 l
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51.5 485.61 m
425.9 485.61 l
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1 w
BT
/F6 10 Tf
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(Attention:) Tj
ET
BT
/F2 10 Tf
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(If you receive outpatient hospital services in an out-of-network) Tj
ET
BT
/F2 10 Tf
1 0 0 1 56.15 482.42 Tm
(hospital in the Alabama service area, no benefits are payable under the plan) Tj
ET
BT
/F2 10 Tf
1 0 0 1 56.15 469.2 Tm
(unless services are to treat an accidental injury or medical emergency.) Tj
ET
1.5 w
[] 0 d
0 0 0 RG
0.15 w
[] 0 d
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51.42 465.02 l
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[] 0 d
50.08 509.05 m
50.08 463.67 l
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1 w
[] 0 d
1.5 w
[] 0 d
0.15 w
[] 0 d
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425.82 463.67 l
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[] 0 d
424.47 507.7 m
424.47 465.02 l
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1 w
[] 0 d
1.5 w
[] 0 d
2 J
0.15 w
[] 0 d
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424.47 507.77 l
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[] 0 d
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425.82 509.12 l
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0 J
1.5 w
[] 0 d
2 J
0.15 w
[] 0 d
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425.82 463.6 l
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[] 0 d
51.42 464.95 m
424.47 464.95 l
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1 w
[] 0 d
BT
/F2 10 Tf
1 0 0 1 0 446.47 Tm
(Outpatient hospital benefits include provider-administered drugs.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 291.27 446.47 Tm
(You can find more information about) Tj
ET
BT
/F2 10 Tf
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(provider-administered drugs in the) Tj
ET
0 0 1 rg
BT
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(Medical Necessity and Precertification) Tj
ET
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323.11 433.55 l
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1 w
[] 0 d
0 0 0 rg
BT
/F2 10 Tf
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( section of this booklet.) Tj
ET
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/F2 10 Tf
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(We may reclassify services or supplies provided to a hospital patient to a level of care determined by us) Tj
ET
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/F2 10 Tf
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(to be medically appropriate given the patient�s condition, the services rendered, and the setting in which) Tj
ET
BT
/F2 10 Tf
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(they were rendered.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 94.5 392.48 Tm
(This means that we may, at times, reclassify an outpatient hospital service as an) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 380.98 Tm
(inpatient admission.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 93.94 380.98 Tm
(There may also be times in which we deny benefits altogether based upon our) Tj
ET
BT
/F2 10 Tf
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(determination that services or supplies were furnished at an inappropriate level of care.) Tj
ET
BT
/F6 12 Tf
1 0 0 1 0 344.17 Tm
(Physician Benefits) Tj
ET
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0 J
44.17 w
51.5 303.15 m
425.9 303.15 l
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1 w
BT
/F6 10 Tf
1 0 0 1 56.15 313.18 Tm
(Attention:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 108.91 313.18 Tm
(Precertification is required for certain physician benefits.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 362.37 313.18 Tm
(You can find) Tj
ET
BT
/F2 10 Tf
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(more information about this in the) Tj
ET
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BT
/F2 10 Tf
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(Medical Necessity and Precertification) Tj
ET
2 J
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[] 0 d
0 0 1 RG
207.71 298.53 m
375.93 298.53 l
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1 w
[] 0 d
0 0 0 rg
BT
/F2 10 Tf
1 0 0 1 376.3 299.96 Tm
( section) Tj
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BT
/F2 10 Tf
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(of this booklet.) Tj
ET
0 J
1.5 w
[] 0 d
0 0 0 RG
0.15 w
[] 0 d
51.42 325.23 m
51.42 282.56 l
S
[] 0 d
50.08 326.58 m
50.08 281.21 l
S
1 w
[] 0 d
1.5 w
[] 0 d
0.15 w
[] 0 d
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425.82 281.21 l
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[] 0 d
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424.47 282.56 l
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1 w
[] 0 d
1.5 w
[] 0 d
2 J
0.15 w
[] 0 d
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424.47 325.31 l
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[] 0 d
50.08 326.66 m
425.82 326.66 l
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1 w
[] 0 d
0 J
1.5 w
[] 0 d
2 J
0.15 w
[] 0 d
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425.82 281.14 l
S
[] 0 d
51.42 282.49 m
424.47 282.49 l
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1 w
[] 0 d
BT
/F2 10 Tf
1 0 0 1 0 264.01 Tm
(The benefits listed below apply only to the physician�s charges for the services indicated.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 397.44 264.01 Tm
(Claims for) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 252.51 Tm
(outpatient facility charges associated with any of these services will be processed under your outpatient) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 241.01 Tm
(hospital benefits and subject to any applicable outpatient facility copayments.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 346.32 241.01 Tm
(Examples may include 1\)) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 229.51 Tm
(laboratory testing performed in the physician�s office, but sent to an outpatient hospital facility for) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 218.01 Tm
(processing; 2\) operating room and related services for surgical procedures performed in the outpatient) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 206.51 Tm
(hospital facility.) Tj
ET
0.8 0.8 0.8 RG
0 J
29.45 w
-5.4 177.34 m
150.1 177.34 l
S
1 w
29.45 w
150.6 177.34 m
306.1 177.34 l
S
1 w
29.45 w
306.6 177.34 m
462.1 177.34 l
S
1 w
13.22 w
-0.25 182.46 m
144.95 182.46 l
S
1 w
BT
/F6 10 Tf
1 0 0 1 20.12 180.02 Tm
(SERVICE OR SUPPLY) Tj
ET
26.45 w
155.75 175.84 m
300.95 175.84 l
S
1 w
BT
/F6 10 Tf
1 0 0 1 195.86 180.02 Tm
(IN-NETWORK) Tj
ET
BT
/F6 10 Tf
1 0 0 1 199.73 166.79 Tm
(PLAN PAYS) Tj
ET
26.45 w
311.75 175.84 m
456.95 175.84 l
S
1 w
BT
/F6 10 Tf
1 0 0 1 337.69 180.02 Tm
(OUT-OF-NETWORK) Tj
ET
BT
/F6 10 Tf
1 0 0 1 355.73 166.79 Tm
(PLAN PAYS) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 151.88 Tm
(Office visits, consultations and) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 141.3 Tm
(psychotherapy) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 151.88 Tm
(100% of the allowed amount, no) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 141.3 Tm
(deductible, subject to a $25 copayment) Tj
ET
BT
/F6 8 Tf
1 0 0 1 311.75 151.88 Tm
(Outside Alabama:) Tj
ET
BT
/F2 8 Tf
1 0 0 1 381.99 151.88 Tm
(80% of the allowed) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 141.3 Tm
(amount, subject to the calendar year) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 130.72 Tm
(deductible) Tj
ET
BT
/F6 8 Tf
1 0 0 1 311.75 117.14 Tm
(In Alabama:) Tj
ET
BT
/F2 8 Tf
1 0 0 1 359.32 117.14 Tm
(50% of the allowed) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 106.56 Tm
(amount, subject to the calendar year) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 95.98 Tm
(deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 81.9 Tm
(Emergency room physician) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 81.9 Tm
(100% of the allowed amount, no) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 71.33 Tm
(deductible, subject to a $25 copayment) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 57.75 Tm
(Mental health disorders and substance) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 47.17 Tm
(abuse services:100% of the allowed) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 36.59 Tm
(amount, no deductible, subject to a $25) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 26.01 Tm
(copayment) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 81.9 Tm
(100% of the allowed amount, no) Tj
ET
BT
/F2 8 Tf
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(In Alabama:) Tj
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/F6 10 Tf
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/F2 8 Tf
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BT
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ET
BT
/F2 8 Tf
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ET
BT
/F2 8 Tf
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ET
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ET
BT
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ET
BT
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(Routine immunizations:) Tj
ET
BT
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(100% of the allowed amount, no) Tj
ET
BT
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(deductible or copayment) Tj
ET
BT
/F2 8 Tf
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BT
/F2 8 Tf
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ET
BT
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BT
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ET
BT
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BT
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BT
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ET
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(deductible or copayment) Tj
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BT
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(testing:) Tj
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BT
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(100% of the allowed amount, no) Tj
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(deductible or copayment) Tj
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(deductible or copayment) Tj
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BT
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BT
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BT
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BT
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BT
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BT
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BT
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ET
BT
/F2 8 Tf
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(and over:) Tj
ET
BT
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(x) Tj
ET
BT
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ET
BT
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ET
BT
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(x) Tj
ET
BT
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BT
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(every three calendar years) Tj
ET
BT
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(x) Tj
ET
BT
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ET
BT
/F2 8 Tf
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ET
BT
/F2 8 Tf
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(calendar years) Tj
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BT
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(x) Tj
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BT
/F2 8 Tf
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ET
BT
/F2 8 Tf
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(calendar years) Tj
ET
BT
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(x) Tj
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BT
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ET
BT
/F2 8 Tf
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ET
BT
/F2 8 Tf
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(years) Tj
ET
BT
/F2 8 Tf
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ET
BT
/F2 8 Tf
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(deductible or copayment) Tj
ET
BT
/F2 8 Tf
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ET
BT
/F2 8 Tf
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BT
/F2 8 Tf
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BT
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BT
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(copayments) Tj
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BT
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ET
BT
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ET
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(.) Tj
ET
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/F2 10 Tf
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ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
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(1.) Tj
ET
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(2.) Tj
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ET
BT
/F2 10 Tf
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(search.) Tj
ET
BT
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(3.) Tj
ET
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/F2 10 Tf
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(Click the Search button to find a pharmacy in the Vaccine Network.) Tj
ET
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(.) Tj
ET
BT
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ET
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/F6 12 Tf
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(Abuse) Tj
ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
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ET
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ET
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/F2 10 Tf
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ET
BT
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ET
BT
/F2 10 Tf
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(.) Tj
ET
BT
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ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
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(Alabama and in a few locations in states bordering Alabama.) Tj
ET
BT
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(A list of EPS providers can be found in the) Tj
ET
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(x) Tj
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BT
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(x) Tj
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(x) Tj
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/F2 10 Tf
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(x) Tj
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BT
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(x) Tj
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BT
/F2 10 Tf
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(Services related to narcotic maintenance therapy such as methadone maintenance therapy;) Tj
ET
BT
/F411 10 Tf
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(x) Tj
ET
BT
/F2 10 Tf
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(Services related to nicotine addiction;) Tj
ET
BT
/F411 10 Tf
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(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 274.76 Tm
(Sex therapy programs or treatment for sex offenders;) Tj
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/F411 10 Tf
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(x) Tj
ET
BT
/F2 10 Tf
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(Prescription drugs; and,) Tj
ET
BT
/F411 10 Tf
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(x) Tj
ET
BT
/F2 10 Tf
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(Residential psychiatric facilities.) Tj
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(Note: See) Tj
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/F2 10 Tf
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(Attention:) Tj
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BT
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ET
BT
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ET
BT
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ET
BT
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ET
BT
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ET
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ET
BT
/F2 8 Tf
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ET
BT
/F2 8 Tf
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ET
BT
/F2 8 Tf
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(treatment beyond 180 days must be pre-) Tj
ET
BT
/F2 8 Tf
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(authorized and is limited to 18 months) Tj
ET
BT
/F2 8 Tf
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(from the date of injury) Tj
ET
BT
/F2 8 Tf
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(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
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(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 656.06 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 645.48 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 525.61 Tm
(Ambulance services) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 525.61 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 515.03 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 525.61 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 515.03 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 500.95 Tm
(Chiropractic services) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 500.95 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 490.37 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 500.95 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 490.37 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 476.29 Tm
(Dialysis services at a renal dialysis) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 465.71 Tm
(facility) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 476.29 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 465.71 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 476.29 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 465.71 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 451.63 Tm
(DME:) Tj
ET
BT
/F2 8 Tf
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(Durable medical equipment and) Tj
ET
BT
/F2 8 Tf
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(supplies, which consist of the following:) Tj
ET
BT
/F2 8 Tf
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(\(1\) artificial arms and other prosthetics,) Tj
ET
BT
/F2 8 Tf
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(leg braces, and other orthopedic) Tj
ET
BT
/F2 8 Tf
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(devices; and \(2\) medical supplies such) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 398.74 Tm
(as oxygen, crutches, casts, catheters,) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 388.16 Tm
(colostomy bags and supplies, and) Tj
ET
BT
/F2 8 Tf
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(splints) Tj
ET
BT
/F6 8 Tf
1 0 0 1 -0.25 364 Tm
(Note:) Tj
ET
BT
/F2 8 Tf
1 0 0 1 24.64 364 Tm
(For DME the allowed amount will) Tj
ET
BT
/F2 8 Tf
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ET
BT
/F2 8 Tf
1 0 0 1 -0.25 342.84 Tm
(purchase price) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 451.63 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 441.06 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 451.63 Tm
(Non-preferred DME supplier in Alabama:) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 441.06 Tm
(50% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 430.48 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 416.9 Tm
(Non-preferred DME supplier outside) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 406.32 Tm
(Alabama:) Tj
ET
BT
/F2 8 Tf
1 0 0 1 349.99 406.32 Tm
(80% of the allowed amount,) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 395.74 Tm
(subject to the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 328.76 Tm
(Eyeglasses or contact lenses:) Tj
ET
BT
/F2 8 Tf
1 0 0 1 110.03 328.76 Tm
(One pair) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 318.18 Tm
(will be covered if medically necessary to) Tj
ET
BT
/F2 8 Tf
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(replace the human lens function as a) Tj
ET
BT
/F2 8 Tf
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(result of eye surgery or eye injury or) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 286.45 Tm
(defect) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 328.76 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 318.18 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 328.76 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 318.18 Tm
(the calendar year deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 272.37 Tm
(Home health and hospice care) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 258.79 Tm
(In-network home healthcare benefits) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 248.21 Tm
(consist of intermittent home nursing) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 237.63 Tm
(visits and home phototherapy for) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 227.05 Tm
(newborns ordered by your attending) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 216.47 Tm
(physician) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 202.89 Tm
(In-network hospice benefits consist of) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 192.31 Tm
(physician home visits, medical social) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 181.74 Tm
(services, physical therapy, inpatient) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 171.16 Tm
(respite care, home health aide visits) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 160.58 Tm
(from one to four hours, durable medical) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 150 Tm
(equipment and symptom management) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 139.42 Tm
(provided to a member certified by his) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 128.84 Tm
(physician to have less than six months) Tj
ET
BT
/F2 8 Tf
1 0 0 1 -0.25 118.26 Tm
(to live) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 272.37 Tm
(100% of the allowed amount, no) Tj
ET
BT
/F2 8 Tf
1 0 0 1 155.75 261.79 Tm
(deductible) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 272.37 Tm
(80% of the allowed amount, subject to) Tj
ET
BT
/F2 8 Tf
1 0 0 1 311.75 261.79 Tm
(the calendar year deductible) Tj
ET
BT
/F6 8 Tf
1 0 0 1 311.75 248.21 Tm
(Note:) Tj
ET
BT
/F2 8 Tf
1 0 0 1 336.64 248.21 Tm
(In Alabama, not covered) Tj
ET
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(Prescription drug benefits are subject to the following terms and conditions:) Tj
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/F411 10 Tf
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(x) Tj
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(To be eligible for benefits, drugs must be FDA-approved legend drugs prescribed by a physician and) Tj
ET
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/F2 10 Tf
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(dispensed by a licensed pharmacist.) Tj
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/F2 10 Tf
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(Legend drugs are medicines which must by law be labeled,) Tj
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(�Caution:) Tj
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(x) Tj
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(to the plan and Tier 3 having the highest cost to the plan.) Tj
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(Manage My Prescriptions) Tj
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(x) Tj
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(These guidelines can be found in) Tj
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(the pharmacy section of our website.) Tj
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(authorization, step therapy, quantity limitation\) in accordance with the guidelines.) Tj
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(A drug may not be) Tj
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(over-the-counter equivalent drugs available.) Tj
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(The guidelines in some instances also require you to) Tj
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(obtain prior authorization as to the medical necessity of the drug.) Tj
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/F2 10 Tf
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(x) Tj
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(x) Tj
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(x) Tj
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(x) Tj
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(management program is available for members with heart failure, coronary artery disease, diabetes,) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 472.91 Tm
(chronic obstructive pulmonary disease \(COPD\), asthma, and other specialized conditions.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 402.97 472.91 Tm
(This program) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 461.41 Tm
(offers personalized care designed to meet your lifestyle and health concerns.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 345.75 461.41 Tm
(Our staff of healthcare) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 449.91 Tm
(professionals will help you cope with your illness and serve as a source of information and education.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 438.41 Tm
(Participation in the program is completely voluntary.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 234.55 438.41 Tm
(If you would like to enroll in the program or obtain) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 426.91 Tm
(more information, call 1-888-841-5741 \(Monday � Friday, 8 a.m. to 4:45 p.m. CST\), or e-mail) Tj
ET
0 0 1 rg
BT
/F2 10 Tf
1 0 0 1 0 415.42 Tm
(membermanagement@bcbsal.org) Tj
ET
2 J
0.732 w
[] 0 d
0 0 1 RG
0.365 413.99 m
150.97 413.99 l
S
1 w
[] 0 d
0 0 0 rg
BT
/F2 10 Tf
1 0 0 1 151.33 415.42 Tm
(.) Tj
ET
BT
/F6 12 Tf
1 0 0 1 0 367.11 Tm
(Baby Yourself Program) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 347.12 Tm
(Baby Yourself offers individual care b) Tj
ET
BT
/F2 10 Tf
1 0 0 1 165.09 347.12 Tm
(y a regi) Tj
ET
BT
/F2 10 Tf
1 0 0 1 197.88 347.12 Tm
(stered nurse.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 261.8 347.12 Tm
(Please call our nurses at 1-800-222-4379 \(or) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 335.62 Tm
(1-205-733-7065 in Birmingham\) or visit) Tj
ET
0 0 1 rg
BT
/F2 10 Tf
1 0 0 1 175.64 335.62 Tm
(AlabamaBlue.com/BabyYourself) Tj
ET
0.732 w
[] 0 d
176 334.19 m
318.68 334.19 l
S
1 w
[] 0 d
0 0 0 rg
BT
/F2 10 Tf
1 0 0 1 319.04 335.62 Tm
( as soon as you find out you are) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 324.12 Tm
(pregnant.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 47.81 324.12 Tm
(Begin care for you and your baby as early as possible and continue throughout your) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 312.62 Tm
(pregnancy.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 55.03 312.62 Tm
(Your baby has the best chance for a healthy start by early, thorough care while you are) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 301.12 Tm
(pregnant.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 281.62 Tm
(If you fall into one of the following risk categories, please tell your doctor and your Baby Yourself nurse:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 270.13 Tm
(age 35 or older; high blood pressure; diabetes; history of previous premature births; multiple births \(twins,) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 258.63 Tm
(triplets, etc.\).) Tj
ET
BT
/F6 12 Tf
1 0 0 1 0 233.32 Tm
(Organ and Bone Marrow Transplants) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 213.33 Tm
(The organs for which there are benefits are:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 199.55 213.33 Tm
(\(1\) heart; \(2\) liver; \(3\) lungs; \(4\) pancreas/islet cell; \(5\)) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 201.83 Tm
(kidney; and \(6\) intestinal/multivisceral.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 174.52 201.83 Tm
(Bone marrow transplants, which include stem cells and marrow to) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 190.33 Tm
(restore or make stronger the bone marrow function, are also included.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 314.6 190.33 Tm
(All organ and bone marrow) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 178.83 Tm
(transplants \(excluding kidney\) must be performed in a hospital or other facility on our list of approved) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 167.33 Tm
(facilities for that type of transplant and it must have our advance written approval.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 364.64 167.33 Tm
(When we approve a) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 155.83 Tm
(facility for transplant services it is limited to the specific types of transplants stated.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 369.6 155.83 Tm
(Covered transplant) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 144.33 Tm
(benefits for the recipient include any medically necessary hospital, medical-surgical and other services) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 132.84 Tm
(related to the transplant, including blood and blood plasma.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 113.34 Tm
(Transplant benefits for cadaveric donor organ costs are limited to search, removal, storage and the) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 101.84 Tm
(transporting of the organ and removal team.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 82.34 Tm
(Transplant benefits for living donor expenses are limited to:) Tj
ET
BT
/F411 10 Tf
1 0 0 1 0 63.84 Tm
(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 63.84 Tm
(solid organs:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 80.26 63.84 Tm
(testing for related and unrelated donors as pre-approved by us) Tj
ET
BT
/F411 10 Tf
1 0 0 1 0 45.34 Tm
(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 45.34 Tm
(bone marrow:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 84.69 45.34 Tm
(related-donor testing and unrelated-donor search fees and procurement if billed) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 33.84 Tm
(through the National Marrow Donor Program or other recognized marrow registry) Tj
ET
BT
/F411 10 Tf
1 0 0 1 0 15.34 Tm
(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 15.34 Tm
(prediagnostic testing expenses of the actual donor for the approved transplant) Tj
ET
Q
q
Q
Q

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q
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0 0 0 rg
BT
/F2 10 Tf
1 0 0 1 0 2.45 Tm
(28) Tj
ET
Q
q
Q
q
1 0 0 1 72 47.5 cm
0 0 0 rg
BT
/F411 10 Tf
1 0 0 1 0 698.45 Tm
(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 698.45 Tm
(hospital and surgical expenses for removal of the donor organ, and all such services provided to the) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 686.95 Tm
(donor during the admission) Tj
ET
BT
/F411 10 Tf
1 0 0 1 0 668.45 Tm
(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 668.45 Tm
(transportation of the donated organ) Tj
ET
BT
/F411 10 Tf
1 0 0 1 0 649.95 Tm
(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 649.95 Tm
(post-operative hospital, medical, laboratory and other services for the donor related to the organ) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 638.45 Tm
(transplant limited to up to 90 days of follow-up care after date of donation.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 618.95 Tm
(All organ and bone marrow transplant benefits for covered recipient and donor expenses are and will be) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 607.45 Tm
(treated as benefits paid or provided on behalf of the member and will be subject to all terms and) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 595.95 Tm
(conditions of the plan applicable to the member, such as deductibles, copays, coinsurance, and other) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 584.45 Tm
(plan limitations.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 74.48 584.45 Tm
(For example, if the member�s coverage terminates, transplant benefits also will not be) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 572.95 Tm
(available for any donor expenses after the effective date of termination.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 553.46 Tm
(There are no transplant benefits for:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 164.54 553.46 Tm
(\(1\) any investigational/experimental artificial or mechanical devices;) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 541.96 Tm
(\(2\) organ or bone marrow transplants from animals; \(3\) donor costs available through other group) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 530.46 Tm
(coverage; \(4\) if any government funding is provided; \(5\) the recipient if not covered by this plan; \(6\) donor) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 518.96 Tm
(costs if the recipient is not covered by this plan; \(7\) recipient or donor lodging, food, or transportation) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 507.46 Tm
(costs, unless otherwise specifically stated in the plan; \(8\) a condition or disease for which a transplant is) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 495.96 Tm
(considered investigational; \(9\) transplants \(excluding kidney\) performed in a facility not on our approved) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 484.46 Tm
(list for that type or for which we have not given written approval in advance.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 464.96 Tm
(Tissue, cell and any other transplants not listed above are not included in this organ and bone marrow) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 453.46 Tm
(transplant benefit but may be covered under other applicable provisions of the plan when determined to) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 441.96 Tm
(be medically necessary and not investigational.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 214.57 441.96 Tm
(These transplants include but are not limited to:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 430.24 441.96 Tm
(heart) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 430.47 Tm
(valves, tendon, ligaments, meniscus, cornea, cartilage, skin, bone, veins, etc.) Tj
ET
BT
/F6 12 Tf
1 0 0 1 0 405.16 Tm
(Air Medical Transport Service\(s\)) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 385.17 Tm
(If a member is hospitalized while traveling more than 150 miles from home \(calculated as a straight-line) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 373.67 Tm
(distance, not road miles\) air medical transportation is available to transport the member to a network) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 362.17 Tm
(hospital of their choice near their home.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 180.65 362.17 Tm
(Ground ambulance transportation is provided from the hospital) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 350.67 Tm
(to the aircraft and then from the aircraft to the receiving hospital.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 331.17 Tm
(Air medical transportation is also available in some cases when a member needs specialized hospital) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 319.67 Tm
(services in a hospital located more than 150 miles from their primary residence so long as the hospital is) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 308.17 Tm
(located within the country of residence \(United States or Canada only\), the member is unable to travel by) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 296.67 Tm
(commercial means without a medical escort, and the transport is approved by us.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 364.61 296.67 Tm
(This includes transport) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 285.18 Tm
(of transplant recipients.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 265.68 Tm
(There are no deductibles, copayments, or coinsurance applicable and there are no claim forms to file for) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 254.18 Tm
(this service.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 58.35 254.18 Tm
(Members call a toll free hotline 1-877-872-8624 \(available 24 hours a day, 7 days a week\) to) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 242.68 Tm
(request air transport services. There are no restrictions on the number of travel days within the United) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 231.18 Tm
(States but services are available only twice per calendar year per member and are not available to) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 219.68 Tm
(members travelling outside the United States for more than 90 consecutive days.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 362.96 219.68 Tm
(Services are also not) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 208.18 Tm
(available for \(1\) any location where the U.S. State Department has issued travel restrictions or declared) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 196.68 Tm
(to be high risk areas; \(2\) any member with tuberculosis or other chronic airborne pathogens; \(3\) in most) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 185.18 Tm
(instances, a member beyond the second trimester of pregnancy; \(4\) members with simple injuries or mild) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 173.68 Tm
(illnesses which do not require hospitalization.) Tj
ET
BT
/F6 12 Tf
1 0 0 1 0 148.37 Tm
(Women�s Health and Cancer Rights Act Information) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 128.39 Tm
(A member who is receiving benefits in connection with a mastectomy will also receive coverage for) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 116.89 Tm
(reconstruction of the breast on which a mastectomy was performed and reconstruction of the other breast) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 105.39 Tm
(to produce a symmetrical appearance; prostheses; and treatment of physical complications at all stages) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 93.89 Tm
(of the mastectomy, including lymphedema.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 195.09 93.89 Tm
(Benefits for this treatment will be subject to the same) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 82.39 Tm
(calendar year deductible and coinsurance provisions that apply for other medical and surgical benefits.) Tj
ET
BT
/F6 18 Tf
1 0 0 1 0 51.65 Tm
(COORDINATION OF BENEFITS \(COB\)) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 30.19 Tm
(COB is a provision designed to help manage the cost of healthcare by avoiding duplication of benefits) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 18.69 Tm
(when a person is covered by two or more benefit plans.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 250.69 18.69 Tm
(COB provisions determine which plan is primary) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 7.19 Tm
(and which is secondary.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 112.28 7.19 Tm
(A primary plan is one whose benefits for a person�s healthcare coverage must) Tj
ET
Q
q
Q
Q

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q
0 0 612 792 re
W
n
q
1 0 0 1 72 36 cm
0 0 0 rg
BT
/F2 10 Tf
1 0 0 1 456.88 14.2 Tm
(29) Tj
ET
Q
q
Q
q
1 0 0 1 72 59.25 cm
0 0 0 rg
BT
/F2 10 Tf
1 0 0 1 0 687.7 Tm
(be determined first without taking the existence of any other plan into consideration.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 375.22 687.7 Tm
(A secondary plan is) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 676.2 Tm
(one which takes into consideration the benefits of the primary plan before determining benefits available) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 664.7 Tm
(under its plan.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 68.37 664.7 Tm
(Some COB terms have defined meanings.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 261.25 664.7 Tm
(These terms are set forth at the end of this) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 653.2 Tm
(COB section.) Tj
ET
BT
/F6 12 Tf
1 0 0 1 0 627.89 Tm
(Order of Benefit Determination) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 607.9 Tm
(Which plan is primary is decided by the first rule below that applies:) Tj
ET
BT
/F6 10 Tf
1 0 0 1 0 588.4 Tm
(Noncompliant Plan:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 99.45 588.4 Tm
(If the other plan is a noncompliant plan, then the other plan shall be primary and) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 576.9 Tm
(this plan shall be secondary unless the COB terms of both plans provide that this plan is primary.) Tj
ET
BT
/F6 10 Tf
1 0 0 1 0 557.4 Tm
(Employee/Dependent:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 110.58 557.4 Tm
(The plan covering a patient as an employee, member, subscriber, or contract) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 545.9 Tm
(holder \(that is, other than as a dependent\) is primary over the plan covering the patient as a dependent.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 534.41 Tm
(In some cases, depending upon the size of the group, Medicare secondary payer rules may require us to) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 522.91 Tm
(reverse this order of payment.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 138.39 522.91 Tm
(This can occur when the patient is covered as an inactive or retired) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 511.41 Tm
(employee, is also covered as a dependent of an active employee, and is also covered by Medicare.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 444.7 511.41 Tm
(In) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 499.91 Tm
(this case, the order of benefit determination will be as follows: first, the plan covering the patient as a) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 488.41 Tm
(dependent; second, Medicare; and third, the plan covering the patient as an inactive or retired employee.) Tj
ET
BT
/F6 10 Tf
1 0 0 1 0 468.91 Tm
(Dependent Child � Parents Not Separated or Divorced:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 265.05 468.91 Tm
(If both plans cover the patient as a dependent) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 457.41 Tm
(child of parents who are married or living together \(regardless of whether they have ever been married\),) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 445.91 Tm
(the plan of the parent whose birthday falls earlier in the year will be primary.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 340.17 445.91 Tm
(If the parents have the same) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 434.41 Tm
(birthday, the plan covering the patient longer is primary.) Tj
ET
BT
/F6 10 Tf
1 0 0 1 0 414.91 Tm
(Dependent Child � Separated or Divorced Parents:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 245.62 414.91 Tm
(If two or more plans cover the patient as a) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 403.42 Tm
(dependent child of parents who are divorced, separated, or no longer living together \(regardless of) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 391.92 Tm
(whether they have ever been married\), benefits are determined in this order:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 374.42 Tm
(1) Tj
ET
BT
/F2 10 Tf
1 0 0 1 5.56 374.42 Tm
(.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 374.42 Tm
(If there is no court decree allocating responsibility for the child�s healthcare expenses or healthcare) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 362.92 Tm
(coverage, the order of benefits for the child are as follows:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 36 345.42 Tm
(a) Tj
ET
BT
/F2 10 Tf
1 0 0 1 41.56 345.42 Tm
(.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 72 345.42 Tm
(first, the plan of the custodial parent;) Tj
ET
BT
/F2 10 Tf
1 0 0 1 36 327.92 Tm
(b) Tj
ET
BT
/F2 10 Tf
1 0 0 1 41.56 327.92 Tm
(.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 72 327.92 Tm
(second, the plan covering the custodial parent�s spouse;) Tj
ET
BT
/F2 10 Tf
1 0 0 1 36 310.42 Tm
(c) Tj
ET
BT
/F2 10 Tf
1 0 0 1 41 310.42 Tm
(.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 72 310.42 Tm
(third, the plan covering the non-custodial parent; and,) Tj
ET
BT
/F2 10 Tf
1 0 0 1 36 292.92 Tm
(d) Tj
ET
BT
/F2 10 Tf
1 0 0 1 41.56 292.92 Tm
(.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 72 292.92 Tm
(last, the plan covering the non-custodial parent�s spouse.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 275.42 Tm
(2) Tj
ET
BT
/F2 10 Tf
1 0 0 1 5.56 275.42 Tm
(.) Tj
ET
BT
/F2 10 Tf
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(If a court decree states that a parent is responsible for the dependent child�s healthcare expenses or) Tj
ET
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(healthcare coverage and the plan of that parent has actual knowledge of those terms, the plan of the) Tj
ET
BT
/F2 10 Tf
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(court-ordered parent is primary.) Tj
ET
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/F2 10 Tf
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(If the court-ordered parent has no healthcare coverage for the dependent child, benefits will be) Tj
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(determined in the following order:) Tj
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(a) Tj
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BT
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(.) Tj
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(b) Tj
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(.) Tj
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(second, the plan of the non-court-ordered parent; and,) Tj
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(c) Tj
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(.) Tj
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(third, the plan of the spouse of the non-court-ordered parent.) Tj
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/F2 10 Tf
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(If a court decree states that both parents are responsible for the dependent child�s healthcare) Tj
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(responsibility for the healthcare expenses or healthcare coverage of the dependent child, the) Tj
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(3) Tj
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(.) Tj
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(For a dependent child covered under more than one plan of individuals who are not the parents of the) Tj
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(child, the order of benefits shall be determined, as applicable, under the �birthday rule� as if those) Tj
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(individuals were parents of the child.) Tj
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Q
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(30) Tj
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(Active Employee or Retired or Laid-Off Employee:) Tj
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(1) Tj
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(.) Tj
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(.) Tj
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(benefits, this rule is ignored.) Tj
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(.) Tj
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(COBRA or State Continuation Coverage:) Tj
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(1) Tj
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(.) Tj
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(to state or other federal law is covered under another plan, the plan covering the person as an) Tj
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(employee, member, subscriber or retiree or covering the person as a dependent of an employee,) Tj
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(member, subscriber or retiree is the primary plan and the plan covering that same person pursuant to) Tj
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(COBRA or under a right of continuation pursuant to state or other federal law is the secondary plan.) Tj
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(2) Tj
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(.) Tj
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(If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of) Tj
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(benefits, this rule is ignored.) Tj
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BT
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(3) Tj
ET
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(.) Tj
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(This rule does not apply if the rule in the paragraph �Employee/Dependent� above can determine the) Tj
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(order of benefits.) Tj
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(plan, the COBRA plan will be primary and the spouse�s active plan will be secondary.) Tj
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(Similarly, if a) Tj
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(divorced spouse is receiving COBRA benefits under his or her former spouse�s plan \(the �COBRA) Tj
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BT
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(plan�\) and is also covered as a dependent under a new spouse�s plan, the COBRA plan will be) Tj
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(primary and the new spouse�s plan will be secondary.) Tj
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(Longer/Shorter Length of Coverage:) Tj
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/F2 10 Tf
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(If the preceding rules do not determine the order of benefits, the) Tj
ET
BT
/F2 10 Tf
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(plan that covered the person for the longer period of time is the primary plan and the plan that covered) Tj
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(the person for the shorter period of time is the secondary plan.) Tj
ET
BT
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(Equal Division:) Tj
ET
BT
/F2 10 Tf
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(If the plans cannot agree on the order of benefits within thirty \(30\) calendar days after) Tj
ET
BT
/F2 10 Tf
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(the plans have received all of the information needed to pay the claim, the plans shall immediately pay) Tj
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(the claim in equal shares and determine their relative liabilities following payment, except that no plan) Tj
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/F2 10 Tf
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(shall be required to pay more than it would have paid had it been the primary plan.) Tj
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(Determination of Amount of Payment) Tj
ET
BT
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(1) Tj
ET
BT
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(.) Tj
ET
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(If this plan is primary, it shall pay benefits as if the secondary plan did not exist.) Tj
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(2) Tj
ET
BT
/F2 10 Tf
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(.) Tj
ET
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/F2 10 Tf
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(If our records indicate this plan is secondary, we will not process your claims until you have filed them) Tj
ET
BT
/F2 10 Tf
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(with the primary plan and the primary plan has made its benefit determination.) Tj
ET
BT
/F2 10 Tf
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(If this plan is a secondary plan on a claim, should it wish to coordinate benefits \(that is, pay benefits as a) Tj
ET
BT
/F2 10 Tf
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(secondary plan rather than as a primary plan with respect to that claim\), this plan shall calculate the) Tj
ET
BT
/F2 10 Tf
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(benefits it would have paid on the claim in the absence of other healthcare coverage and apply that) Tj
ET
BT
/F2 10 Tf
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(calculated amount to any allowable expense under its plan that is unpaid by the primary plan.) Tj
ET
BT
/F2 10 Tf
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(When) Tj
ET
BT
/F2 10 Tf
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(paying secondary, this plan may reduce its payment by the amount so that, when combined with the) Tj
ET
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(amount paid by the primary plan, the total benefits paid or provided by all plans for the claim do not) Tj
ET
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(exceed 100 percent of the total allowable expense for that claim.) Tj
ET
BT
/F2 10 Tf
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(In addition, the secondary plan shall) Tj
ET
BT
/F2 10 Tf
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(credit to its plan deductible any amounts it would have credited to its deductible in the absence of other) Tj
ET
BT
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(healthcare coverage.) Tj
ET
BT
/F2 10 Tf
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(In some instances, when this plan is a secondary plan, it may be more cost) Tj
ET
BT
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(effective for the plan to pay on a claim as if it were the primary plan.) Tj
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(If the plan elects to pay a claim as if) Tj
ET
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(it were primary, it shall calculate and pay benefits as if no other coverage were involved.) Tj
ET
Q
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(31) Tj
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(COB Terms) Tj
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(Allowable Expense:) Tj
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BT
/F2 10 Tf
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(applicable deductible that is covered in full or in part by any of the plans covering the person.) Tj
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/F2 10 Tf
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(The term �allowable expense� does not include the following:) Tj
ET
BT
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(x) Tj
ET
BT
/F2 10 Tf
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(An expense or a portion of an expense that is not covered by any of the plans.) Tj
ET
BT
/F411 10 Tf
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(x) Tj
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(Any expense that a provider by law or in accordance with a contractual agreement is prohibited) Tj
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(from charging a covered person.) Tj
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(x) Tj
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(Any type of coverage or benefit not provided under this plan.) Tj
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/F2 10 Tf
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(For example, if this plan does not) Tj
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(provide benefits for mental health disorders and substance abuse, dental services and supplies,) Tj
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(vision care, prescriptions drugs, or hearing aids, or other similar type of coverage or benefit, then) Tj
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(it will have no secondary liability with respect to such coverage or benefit.) Tj
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(In addition, the term) Tj
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(�allowable expense� does not include the amount of any reduction in benefits under a primary) Tj
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(plan because \(a\) the covered person failed to comply with the primary plan�s provisions) Tj
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(concerning second surgical opinions or precertification of admissions or services, or \(b\), the) Tj
ET
BT
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(covered person had a lower benefit because he or she did not use a preferred provider.) Tj
ET
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/F6 10 Tf
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(Birthday:) Tj
ET
BT
/F2 10 Tf
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(The term �birthday� refers only to month and day in a calendar year and does not include the) Tj
ET
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(year in which the individual is born.) Tj
ET
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(Custodial Parent:) Tj
ET
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/F2 10 Tf
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(The term �custodial parent� means:) Tj
ET
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(x) Tj
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(A parent awarded custody of a child by a court decree; or,) Tj
ET
BT
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(x) Tj
ET
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/F2 10 Tf
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(In the absence of a court decree, the parent with whom the child resides for more than one half of) Tj
ET
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(the calendar year without regard to any temporary visitation.) Tj
ET
BT
/F6 10 Tf
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(Group-Type Contract:) Tj
ET
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/F2 10 Tf
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(The term �group-type contract� means a contract that is not available to the) Tj
ET
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(general public and is obtained and maintained only because of membership in or a connection with a) Tj
ET
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/F2 10 Tf
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(particular organization or group, including blanket coverage.) Tj
ET
BT
/F2 10 Tf
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(The term does not include an individually) Tj
ET
BT
/F2 10 Tf
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(underwritten and issued guaranteed renewable policy even if the policy is purchased through payroll) Tj
ET
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/F2 10 Tf
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(deduction at a premium savings to the insured since the insured would have the right to maintain or) Tj
ET
BT
/F2 10 Tf
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(renew the policy independently of continued employment with the employer.) Tj
ET
BT
/F6 10 Tf
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(Hospital Indemnity Benefits:) Tj
ET
BT
/F2 10 Tf
1 0 0 1 140.57 280.42 Tm
(The term �hospital indemnity benefits� means benefits not related to) Tj
ET
BT
/F2 10 Tf
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(expenses incurred.) Tj
ET
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/F2 10 Tf
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(The term does not include reimbursement-type benefits even if they are designed or) Tj
ET
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(administered to give the insured the right to elect indemnity-type benefits at the time of claim.) Tj
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(Noncompliant Plan:) Tj
ET
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/F2 10 Tf
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(The term �noncompliant plan� means a plan with COB rules that are inconsistent in) Tj
ET
BT
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(substance with the order of benefit determination rules of this plan.) Tj
ET
BT
/F2 10 Tf
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(Examples of noncompliant plans are) Tj
ET
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/F2 10 Tf
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ET
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(Plan:) Tj
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(The term �plan� includes group insurance contracts, health maintenance organization \(HMO\)) Tj
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(uninsured\); medical care components of long-term care contracts, such as skilled nursing care; medical) Tj
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/F2 10 Tf
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(plan, as permitted by law.) Tj
ET
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/F2 10 Tf
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(The term �plan� does not include non-group or individual health or medical reimbursement insurance) Tj
ET
BT
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(contracts.) Tj
ET
BT
/F2 10 Tf
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(The term �plan� also does not include hospital indemnity coverage or other fixed indemnity) Tj
ET
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/F2 10 Tf
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(coverage; accident-only coverage; specified disease or specified accident coverage; limited benefit health) Tj
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(federal governmental plans, unless permitted by law.) Tj
ET
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(Primary Plan:) Tj
ET
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(The term �primary plan� means a plan whose benefits for a person�s health care coverage) Tj
ET
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ET
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ET
BT
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(plan if:) Tj
ET
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(person.) Tj
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/F2 10 Tf
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(have paid or provided.) Tj
ET
BT
/F2 10 Tf
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(That means that we may use your right to recover money from that other person) Tj
ET
BT
/F2 10 Tf
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(or organization.) Tj
ET
BT
/F6 12 Tf
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(Right of Reimbursement) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 91.49 Tm
(Besides the right of subrogation, we have a separate right to be reimbursed or repaid from any money) Tj
ET
BT
/F2 10 Tf
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(you, including your family members, recover for an injury or condition for which we have paid plan) Tj
ET
BT
/F2 10 Tf
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(benefits.) Tj
ET
BT
/F2 10 Tf
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(This means that you promise to repay us from any money you recover the amount we have) Tj
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(paid or provided in plan benefits.) Tj
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BT
/F2 10 Tf
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(lawsuit, whether by settlement or otherwise, you must repay us.) Tj
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BT
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(you must repay us.) Tj
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(In these and all other cases, you must repay us.) Tj
ET
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(We have the right to be reimbursed or repaid first from any money you recover, even if you are not paid) Tj
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ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
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BT
/F2 10 Tf
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(recoveries from other persons or organizations and to fully assist and cooperate with us in protecting and) Tj
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(obtaining our reimbursement and subrogation rights in accordance with this section.) Tj
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(notify us so that we are able to and do recover the amount of our benefit payments for you, we will share) Tj
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(proportionately with you in any attorney�s fees charged to you by your attorney for obtaining the recovery.) Tj
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/F2 10 Tf
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(bankruptcy court\), our reimbursement or subrogation recovery under this section will not be decreased by) Tj
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(any attorney's fee for your attorney or under the common fund theory.) Tj
ET
BT
/F2 10 Tf
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(You further agree not to allow our reimbursement and subrogation rights under this plan to be limited or) Tj
ET
BT
/F2 10 Tf
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(harmed by any other acts or failures to act on your part.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 251.24 430.91 Tm
(It is understood and agreed that if you do, we) Tj
ET
BT
/F2 10 Tf
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(may suspend or terminate payment or provision of any further benefits for you under the plan.) Tj
ET
BT
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(HEALTH BENEFIT EXCLUSIONS) Tj
ET
BT
/F2 10 Tf
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(In addition to other exclusions set forth in this booklet, we) Tj
ET
BT
/F6 10 Tf
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(will not) Tj
ET
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/F2 10 Tf
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( provide benefits under any portion of) Tj
ET
BT
/F2 10 Tf
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(this booklet for the following:) Tj
ET
BT
/F2 18 Tf
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(A) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 307.52 Tm
(Services or expenses for) Tj
ET
BT
/F6 10 Tf
1 0 0 1 112.83 307.52 Tm
(acupuncture) Tj
ET
BT
/F2 10 Tf
1 0 0 1 172.84 307.52 Tm
(, biofeedback, behavioral modification and other forms of self-care) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 296.02 Tm
(or self-help training.) Tj
ET
BT
/F6 10 Tf
1 0 0 1 0 276.52 Tm
(Anesthesia) Tj
ET
BT
/F2 10 Tf
1 0 0 1 53.35 276.52 Tm
( services or supplies or both by local infiltration.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 257.02 Tm
(Services, care, treatment, or supplies furnished by a provider that is not recognized by us as an) Tj
ET
BT
/F6 10 Tf
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(approved provider) Tj
ET
BT
/F2 10 Tf
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( for the type of service or supply being furnished.) Tj
ET
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/F2 10 Tf
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(For example, we reserve the right) Tj
ET
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ET
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(\(M.D.s\), even if the services or supplies are within the scope of the provider�s license.) Tj
ET
BT
/F2 10 Tf
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(Call Customer) Tj
ET
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/F2 10 Tf
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(Service if you have any question as to whether your provider is recognized as an approved provider for) Tj
ET
BT
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(the services or supplies that you intend to receive.) Tj
ET
BT
/F2 10 Tf
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(Services or expenses for or related to) Tj
ET
BT
/F6 10 Tf
1 0 0 1 168.97 180.03 Tm
(Assisted Reproductive Technology \(ART\)) Tj
ET
BT
/F2 10 Tf
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(.) Tj
ET
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/F2 10 Tf
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ET
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(of taking human eggs or sperm or both and putting them into a medium or the body to try to cause) Tj
ET
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(reproduction.) Tj
ET
BT
/F2 10 Tf
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(Examples of ART are in vitro fertilization and gamete intrafallopian transfer.) Tj
ET
BT
/F2 18 Tf
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(C) Tj
ET
BT
/F2 10 Tf
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(Services or expenses of a hospital stay, except one for an emergency, unless we) Tj
ET
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/F6 10 Tf
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(certify) Tj
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/F2 10 Tf
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( it before your) Tj
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(admission.) Tj
ET
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/F2 10 Tf
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(Services or expenses of a hospital stay for an emergency if we are not notified within 48) Tj
ET
BT
/F2 10 Tf
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/F2 10 Tf
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(Services or expenses for which a) Tj
ET
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(claim) Tj
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(not received within 24 months) Tj
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( after services were rendered) Tj
ET
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/F2 10 Tf
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(or expenses incurred.) Tj
ET
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/F2 10 Tf
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/F2 10 Tf
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(weights or variable resistance machinery, and equipment producing isolated muscle evaluations and) Tj
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/F2 10 Tf
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ET
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(home.) Tj
ET
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/F2 10 Tf
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(Services or expenses for cosmetic surgery.) Tj
ET
BT
/F6 10 Tf
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ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
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(or change the way one appears.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 148.43 579.96 Tm
(�Reconstructive surgery� is any surgery done primarily to restore or) Tj
ET
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/F2 10 Tf
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(improve the way the body works or correct deformities that result from disease, trauma or birth defects.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 556.96 Tm
(Reconstructive surgery is a covered benefit; cosmetic surgery is not.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 307.9 556.96 Tm
(Complications or later surgery) Tj
ET
BT
/F2 10 Tf
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(related in any way to cosmetic surgery is not covered, even if medically necessary, if caused by an) Tj
ET
BT
/F2 10 Tf
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(accident, or if done for mental or emotional relief.) Tj
ET
BT
/F411 10 Tf
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(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 515.46 Tm
(You must contact us prior to surgery to find out whether a procedure will be reconstructive or) Tj
ET
BT
/F2 10 Tf
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(cosmetic.) Tj
ET
BT
/F2 10 Tf
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(You and your physician must prove to our satisfaction that surgery is reconstructive and) Tj
ET
BT
/F2 10 Tf
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(not cosmetic.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 82.47 492.46 Tm
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ET
BT
/F2 10 Tf
1 0 0 1 18 480.96 Tm
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ET
BT
/F2 10 Tf
1 0 0 1 206.42 480.96 Tm
(We may not be able to determine prior to your surgery) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 469.47 Tm
(whether or not the proposed procedure will be considered cosmetic.) Tj
ET
BT
/F411 10 Tf
1 0 0 1 0 450.97 Tm
(x) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 450.97 Tm
(Some surgery is always cosmetic such as ear piercing, neck tucks, face lifts, buttock and thigh lifts,) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 439.47 Tm
(implants to small but normal breasts \(except as provided by the Women's Health and Cancer Rights) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 427.97 Tm
(Act\), hair implants for male-pattern baldness and correction of frown lines on the forehead.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 423.21 427.97 Tm
(In other) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 416.47 Tm
(surgery, such as blepharoplasty \(eyelids\), rhinoplasty \(nose\), chemical peel and chin implants, it) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 404.97 Tm
(depends on why that procedure was done.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 212.02 404.97 Tm
(For example, a person with a deviated septum may have) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 393.47 Tm
(trouble breathing and may have many sinus infections.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 265.36 393.47 Tm
(To correct this they have septoplasty.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 436.56 393.47 Tm
(During) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 381.97 Tm
(surgery the physician may remove a hump or shorten the nose \(rhinoplasty\).) Tj
ET
BT
/F2 10 Tf
1 0 0 1 361.5 381.97 Tm
(The septoplasty would) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 370.47 Tm
(be reconstructive surgery while the rhinoplasty would be denied as cosmetic surgery.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 399.3 370.47 Tm
(Surgery to) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 358.97 Tm
(remove excess skin from the eyelids \(blepharoplasty\) would be cosmetic if done to improve your) Tj
ET
BT
/F2 10 Tf
1 0 0 1 18 347.47 Tm
(appearance, but reconstructive if done because your eyelids kept you from seeing very well.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 327.98 Tm
(Services or expenses for treatment of injury sustained in the commission of a) Tj
ET
BT
/F6 10 Tf
1 0 0 1 343.49 327.98 Tm
(crime) Tj
ET
BT
/F2 10 Tf
1 0 0 1 370.18 327.98 Tm
( \(except for treatment) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 316.48 Tm
(of injury as a result of a medical condition or as a result of domestic violence\) or for treatment while) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 304.98 Tm
(confined in a prison, jail, or other penal institution.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 285.48 Tm
(Services or expenses for) Tj
ET
BT
/F6 10 Tf
1 0 0 1 112.83 285.48 Tm
(custodial care) Tj
ET
BT
/F2 10 Tf
1 0 0 1 180.08 285.48 Tm
(.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 188.41 285.48 Tm
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ET
BT
/F2 10 Tf
1 0 0 1 0 273.98 Tm
(and board, routine nursing care, training in personal hygiene, and other forms of self-care or supervisory) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 262.48 Tm
(care by a physician for a person who is mentally or physically disabled.) Tj
ET
BT
/F2 18 Tf
1 0 0 1 0 235.74 Tm
(D) Tj
ET
BT
/F6 10 Tf
1 0 0 1 0 214.28 Tm
(Dental) Tj
ET
BT
/F2 10 Tf
1 0 0 1 33.34 214.28 Tm
(implants into, across, or just above the bone and related appliances.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 340.75 214.28 Tm
(Services or expenses to) Tj
ET
BT
/F2 10 Tf
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(prepare the mouth for dental implants such as those to increase the upper and lower jaws or their) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 191.28 Tm
(borders, sinus lift process, guided tissue regrowth or any other surgery, bone grafts, hydroxyapatite and) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 179.79 Tm
(similar materials.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 80.57 179.79 Tm
(These services, supplies or expenses are not covered even if they are needed to treat) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 168.29 Tm
(conditions existing at birth, while growing, or resulting from an accident.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 321.27 168.29 Tm
(These services, supplies or) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 156.79 Tm
(expenses are excluded even if they are medically or dentally necessary.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 137.29 Tm
(Except as may be otherwise expressly covered in this booklet,) Tj
ET
BT
/F6 10 Tf
1 0 0 1 277.91 137.29 Tm
(dietary) Tj
ET
BT
/F2 10 Tf
1 0 0 1 310.7 137.29 Tm
( instructions.) Tj
ET
BT
/F2 18 Tf
1 0 0 1 0 110.55 Tm
(E) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 89.09 Tm
(Services, care, or treatment you receive after the) Tj
ET
BT
/F6 10 Tf
1 0 0 1 218.98 89.09 Tm
(ending date of your coverage.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 366.79 89.09 Tm
(This means, for) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 77.59 Tm
(example, that if you are in the hospital when your coverage ends, we will not pay for any more hospital) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 66.09 Tm
(days.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 29.46 66.09 Tm
(We do not insure against any condition such as pregnancy or injury.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 335.19 66.09 Tm
(We provide benefits only for) Tj
ET
BT
/F2 10 Tf
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ET
BT
/F6 10 Tf
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(Eyeglasses) Tj
ET
BT
/F2 10 Tf
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(set forth in the section of this booklet called) Tj
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(Other Covered Services) Tj
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ET
BT
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ET
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ET
BT
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ET
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(F) Tj
ET
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ET
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ET
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ET
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(\(except mycotic nails\).) Tj
ET
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(G) Tj
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(Unless otherwise required by applicable law, services or expenses covered in whole or in part under the) Tj
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(H) Tj
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(Hearing aids) Tj
ET
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/F2 10 Tf
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(I) Tj
ET
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(Investigational) Tj
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/F2 10 Tf
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/F2 18 Tf
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(L) Tj
ET
BT
/F2 10 Tf
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(Services or expenses that you are not) Tj
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BT
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(, or for which no charge would be made if) Tj
ET
BT
/F2 10 Tf
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(you had no health coverage.) Tj
ET
BT
/F2 10 Tf
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(Services or expenses for treatment which does not require a) Tj
ET
BT
/F6 10 Tf
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(licensed provider) Tj
ET
BT
/F2 10 Tf
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(, given the level of) Tj
ET
BT
/F2 10 Tf
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(simplicity and the patient's condition, will not further restore or improve the patient's bodily functions, or is) Tj
ET
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/F2 10 Tf
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(not reasonable as to number, frequency, or duration.) Tj
ET
BT
/F2 18 Tf
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(M) Tj
ET
BT
/F2 10 Tf
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(Services or expenses we determine are not) Tj
ET
BT
/F6 10 Tf
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(medically necessary) Tj
ET
BT
/F2 10 Tf
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(.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 248.02 Tm
(Services or supplies to the extent that a member is, or would be, entitled to reimbursement under) Tj
ET
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/F6 10 Tf
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(Medicare) Tj
ET
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ET
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ET
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(Services or expenses for or related to the diagnosis or treatment of) Tj
ET
BT
/F6 10 Tf
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(mental retardation) Tj
ET
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(.) Tj
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(N) Tj
ET
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(Services or expenses of any kind for) Tj
ET
BT
/F6 10 Tf
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(nicotine addiction) Tj
ET
BT
/F2 10 Tf
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(.) Tj
ET
BT
/F2 10 Tf
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(Services, care or treatment you receive during any period of time with respect to which we have) Tj
ET
BT
/F6 10 Tf
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BT
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(paid for your coverage) Tj
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/F6 10 Tf
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(nonpayment) Tj
ET
BT
/F2 10 Tf
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( results in termination.) Tj
ET
BT
/F2 10 Tf
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(Services or expenses rendered by out-of-network Certified Registered) Tj
ET
BT
/F6 10 Tf
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(Nurse Practitioners) Tj
ET
BT
/F2 10 Tf
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( \(CRNP\) or) Tj
ET
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(out-of-network Certified) Tj
ET
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(Nurse Midwives) Tj
ET
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( \(CNM\).) Tj
ET
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/F2 18 Tf
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(O) Tj
ET
BT
/F2 10 Tf
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(Unless otherwise expressly covered under the) Tj
ET
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(Physician Preventive Benefits) Tj
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(services or expenses for treatment of any condition including, but not limited to,) Tj
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ET
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(This exclusion does not apply to surgery for) Tj
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(36) Tj
ET
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q
Q
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1 0 0 1 72 47.5 cm
0 0 0 rg
BT
/F2 10 Tf
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(morbid obesity if medically necessary and in compliance with guidelines of Blue Cross.) Tj
ET
BT
/F2 10 Tf
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(Benefits will only) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 687.95 Tm
(be provided for one surgical procedure for obesity \(morbid\) per member under this plan.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 393.53 687.95 Tm
(Benefits will be) Tj
ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
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(\(morbid\) only if medically necessary and in compliance with the guidelines of Blue Cross.) Tj
ET
BT
/F2 10 Tf
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(However, no) Tj
ET
BT
/F2 10 Tf
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(benefits will be provided for subsequent surgery for complications related to a covered surgical procedure) Tj
ET
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ET
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ET
BT
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(procedure.) Tj
ET
BT
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BT
/F2 10 Tf
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ET
BT
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ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
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ET
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ET
BT
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ET
BT
/F2 10 Tf
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(for any benefits under this plan, unless) Tj
ET
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ET
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(P) Tj
ET
BT
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(Hot and cold) Tj
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ET
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ET
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(.) Tj
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(R) Tj
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ET
BT
/F6 10 Tf
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(recreational) Tj
ET
BT
/F2 10 Tf
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( or educational therapy \(except for plan-approved) Tj
ET
BT
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(diabetic) Tj
ET
BT
/F2 10 Tf
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( self-) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 403.07 Tm
(management programs, pulmonary rehabilitation programs, or Phase 1 or 2 cardiac rehabilitation) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 391.57 Tm
(programs\).) Tj
ET
BT
/F2 10 Tf
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(Hospital admissions in whole or in part when the patient primarily receives services to) Tj
ET
BT
/F6 10 Tf
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(rehabilitate) Tj
ET
BT
/F2 10 Tf
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( such) Tj
ET
BT
/F2 10 Tf
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(as physical therapy, speech therapy, or occupational therapy unless the admission is determined to be) Tj
ET
BT
/F2 10 Tf
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(medically necessary for acute inpatient rehabilitation.) Tj
ET
BT
/F2 10 Tf
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(Services or expenses for learning or vocational) Tj
ET
BT
/F6 10 Tf
1 0 0 1 210.66 329.57 Tm
(rehabilitation) Tj
ET
BT
/F2 10 Tf
1 0 0 1 273.45 329.57 Tm
(.) Tj
ET
BT
/F2 10 Tf
1 0 0 1 0 310.08 Tm
(Services or expenses any provider rendered to a member who is) Tj
ET
BT
/F6 10 Tf
1 0 0 1 289.03 310.08 Tm
(related) Tj
ET
BT
/F2 10 Tf
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ET
BT
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(marriage or who regularly resides in the provider�s household.) Tj
ET
BT
/F2 10 Tf
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(Examples of a provider include a) Tj
ET
BT
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ET
BT
/F2 10 Tf
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(therapist.) Tj
ET
BT
/F6 10 Tf
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(Replacement or upgrade) Tj
ET
BT
/F2 10 Tf
1 0 0 1 117.25 256.08 Tm
( of existing properly functioning durable medical equipment \(including) Tj
ET
BT
/F2 10 Tf
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(prosthetics\), even if the warranty has expired.) Tj
ET
BT
/F6 10 Tf
1 0 0 1 0 225.08 Tm
(Residential treatment.) Tj
ET
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/F2 10 Tf
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/F2 10 Tf
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/F2 10 Tf
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/F2 10 Tf
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/F2 10 Tf
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/F2 10 Tf
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(whether the claim is payable.) Tj
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(If we do this, we will send you a copy of our request.) Tj
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(However, you will) Tj
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(remain responsible for seeing that we get the information on time.) Tj
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(35244-2858.) Tj
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(Non-urgent pre-service claims \(for example, those relating to elective services and supplies\) must be) Tj
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(time.) Tj
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(Emergency admissions to a hospital do not require you to file a pre-service claim so long as you) Tj
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(provide notice to us within 48 hours of the admission and we certify the admission as both medically) Tj
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(necessary and as an emergency admission.) Tj
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(admission if you are admitted to a Concurrent Utilization Review Program \(CURP\) hospital by a Preferred) Tj
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(reviews.) Tj
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(If your plan provides chiropractic, physical therapy, or occupational therapy benefits and you) Tj
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(occupational therapist, your provider is responsible for initiating the precertification process for you.) Tj
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(For) Tj
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(home healthcare and hospice benefits \(if covered by your plan\), see the previous sections of this booklet) Tj
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(for instructions on how to precertify treatment.) Tj
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(If you attempt to file a pre-service claim but fail to follow our procedures for doing so, we will notify you of) Tj
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(Our notification may be oral, unless you ask for it in writing.) Tj
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(We will provide this notification to you only if) Tj
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(\(1\) your attempt to submit a pre-service claim was received by a person or organizational unit of our) Tj
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(company that is customarily responsible for handling benefit matters, and \(2\), your submission contains) Tj
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(the name of a member, a specific medical condition or symptom, and a specific treatment or service for) Tj
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(which approval is being requested.) Tj
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(Urgent Pre-Service Claims:) Tj
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(We will treat your claim as urgent if a delay in processing your claim could) Tj
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(seriously jeopardize your life, health, or ability to regain maximum function or, in the opinion of your) Tj
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(treating physician, a delay would subject you to severe pain that cannot be managed without the care or) Tj
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(treatment that is the subject of your claim.) Tj
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(If your treating physician tells us that your claim is urgent, we) Tj
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(will treat it as such.) Tj
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(If your claim is urgent, we will notify you of our decision within 72 hours. If we need more information, we) Tj
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(will let you know within 24 hours of your claim.) Tj
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(We will tell you what further information we need.) Tj
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(You will) Tj
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(then have 48 hours to provide this information to us.) Tj
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(We will notify you of our decision within 48 hours) Tj
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(after we receive the requested information.) Tj
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(Our response may be oral; if it is, we will follow it up in writing) Tj
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(within three days.) Tj
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(If we do not receive the information, your claim will be considered denied at the) Tj
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(expiration of the 48-hour period we gave you for furnishing the information to us.) Tj
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(Non-Urgent Pre-Service Claims:) Tj
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(If your claim is not urgent, we will notify you of our decision within 15) Tj
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(days.) Tj
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(If we need more information, we will let you know before the 15-day period expires.) Tj
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(We will tell you) Tj
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(what further information we need.) Tj
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(You will then have 90 days to provide this information to us.) Tj
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(In order) Tj
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(to expedite our receipt of the information, we may request it directly from your provider.) Tj
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(If we do this, we) Tj
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(will send you a copy of our request.) Tj
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(However, you will remain responsible for seeing that we get the) Tj
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(information on time.) Tj
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(We will notify you of our decision within 15 days after we receive the requested) Tj
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(information.) Tj
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(If we do not receive the information, your claim will be considered denied at the expiration of) Tj
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(the 90-day period we gave you for furnishing the information to us.) Tj
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(Courtesy Pre-Determinations:) Tj
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(For some procedures we encourage, but do not require, you to contact) Tj
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(For example, if you or your physician thinks a procedure might be) Tj
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(determination, we will do our best to provide you with a timely response.) Tj
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(courtesy pre-determination, you or your provider should call our Customer Service Department.) Tj
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(Concurrent Care Determinations) Tj
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(Determinations by Us to Limit or Reduce Previously Approved Care:) Tj
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(a hospital stay or course of treatment to be provided over a period of time or number of treatments, and) Tj
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(we later decide to limit or reduce the previously approved stay or course of treatment, we will give you) Tj
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(enough advance written notice to permit you to initiate an appeal and obtain a decision before the date on) Tj
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(which care or treatments are no longer approved.) Tj
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/F2 10 Tf
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(You must follow any reasonable rules we establish for) Tj
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(the filing of your appeal, such as time limits within which the appeal must be filed.) Tj
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(Requests by You to Extend Previously Approved Care:) Tj
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(If a previously approved hospital stay or) Tj
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(course of treatment is about to expire, you may submit a request to extend your approved care.) Tj
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(You may) Tj
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(make this request in writing or orally either directly to us or through your treating physician or a hospital) Tj
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(representative.) Tj
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(The phone numbers to call in order to request an extension of care are as follows:) Tj
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(x) Tj
ET
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(For inpatient hospital care, call 1-205-988-2245 or 1-800-248-2342 \(toll-free\).) Tj
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(x) Tj
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(For in-network chiropractic services, physical therapy, speech therapy, or occupational therapy call 1-) Tj
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(205-220-7202.) Tj
ET
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(If your request for additional care is urgent, and if you submit it no later than 24 hours before the end of) Tj
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(your pre-approved stay or course of treatment, we will give you our decision within 24 hours of when your) Tj
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(If your request is not made before this 24-hour time frame, and your request is) Tj
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(If your request is not urgent, we will treat it as) Tj
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(a new claim for benefits, and will make a determination on your claim within the pre-service or post-) Tj
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(service time frames discussed above.) Tj
ET
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(Your Right To Information) Tj
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(You have the right, upon request, to receive copies of any documents that we relied on in reaching our) Tj
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(decision and any documents that were submitted, considered, or generated by us in the course of) Tj
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(reaching our decision.) Tj
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(You also have the right to receive copies of any internal rules, guidelines, or) Tj
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ET
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(If our decision was based on a medical) Tj
ET
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(or scientific determination \(such as medical necessity\), you may also request that we provide you with a) Tj
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(statement explaining our application of those medical and scientific principles to you.) Tj
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(If we obtained) Tj
ET
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(advice from a healthcare professional \(regardless of whether we relied on that advice\), you may request) Tj
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(that we give you the name of that person.) Tj
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(Any request that you make for information under this) Tj
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(paragraph must be in writing.) Tj
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(We will not charge you for any information that you request under this) Tj
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(paragraph.) Tj
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(Appeals) Tj
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(If you are dissatisfied with our adverse benefit determination of a claim, you may file an appeal with us.) Tj
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(You cannot file a claim for benefits under the plan in federal or state court \(or in arbitration if provided by) Tj
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(your plan\) unless you exhaust these administrative remedies.) Tj
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(The rules in this section of this booklet allow you or your authorized representative to appeal any adverse) Tj
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(x) Tj
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(35202-2185) Tj
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(If your appeal arises from our denial of a post-) Tj
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(Alabama, Attention: Customer Service Department - Appeals, P.O. Box 10744, Birmingham, AL 35202-) Tj
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(0744.) Tj
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(If you request an external review, an independent organization will review our decision.) Tj
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(The) Tj
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(in writing) Tj
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(required 60-day notice period.) Tj
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(Parkway East, Birmingham, Alabama 35298-0001, or fax your notice to Blue Cross at 205-220-6884 or 1-) Tj
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(qualifying event will not cover most of your hospital, medical and prescription drug expenses.) Tj
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(Call the) Tj
ET
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(whichever period ends last.) Tj
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(See the) Tj
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ET
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/F2 10 Tf
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/F2 10 Tf
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ET
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(Each of these periodic payments is due on the first day of the month for) Tj
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(that coverage period.) Tj
ET
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/F2 10 Tf
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ET
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/F2 10 Tf
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ET
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/F2 10 Tf
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(However, if you pay a periodic payment later than the first day of the coverage period to which) Tj
ET
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ET
BT
/F2 10 Tf
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ET
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/F2 10 Tf
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ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
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(period for that coverage period, you will lose all rights to COBRA coverage under the plan.) Tj
ET
BT
/F2 10 Tf
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(Payment of your COBRA premiums is deemed made on the day sent.) Tj
ET
BT
/F6 12 Tf
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ET
BT
/F2 10 Tf
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(Your COBRA coverage will terminate early if any of the following events occurs:) Tj
ET
BT
/F411 10 Tf
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(x) Tj
ET
BT
/F2 10 Tf
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ET
BT
/F411 10 Tf
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(x) Tj
ET
BT
/F2 10 Tf
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ET
BT
/F411 10 Tf
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ET
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/F2 10 Tf
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ET
BT
/F411 10 Tf
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(x) Tj
ET
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/F2 10 Tf
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ET
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(x) Tj
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ET
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ET
BT
/F2 10 Tf
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(In addition, COBRA coverage can be terminated if otherwise permitted under the terms of the plan.) Tj
ET
BT
/F2 10 Tf
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(For) Tj
ET
BT
/F2 10 Tf
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(example, if you submit fraudulent claims, your coverage will terminate.) Tj
ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
1 0 0 1 178.44 242.62 Tm
( through Blue Cross, you will cease to receive any benefits) Tj
ET
BT
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(through us for any and all claims incurred after the effective date of termination of our contract with the) Tj
ET
BT
/F2 10 Tf
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ET
BT
/F2 10 Tf
1 0 0 1 33.91 219.62 Tm
(This is true even if we have been billing your COBRA premiums prior to the date of termination.) Tj
ET
BT
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(Department of Labor.) Tj
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(Under a federal law called the) Tj
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(Parkway East, P.O. Box 995, Birmingham, Alabama 35298-0001.) Tj
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(this termination belongs to the group, not to us.) Tj
ET
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(See the) Tj
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2 J
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(booklet.) Tj
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(Inpatient:) Tj
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(A registered bed patient in a hospital; provided that we reserve the right in appropriate cases) Tj
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ET
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(Inpatient Hospital Benefits) Tj
ET
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439.88 578.28 l
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1 w
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/F2 10 Tf
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( and) Tj
ET
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(Outpatient Hospital Benefits) Tj
ET
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(.) Tj
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(Intensive Outpatient:) Tj
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ET
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ET
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(active psychosocial treatment and medication management as needed.) Tj
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(Investigational:) Tj
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(Any treatment, procedure, facility, equipment, drugs, drug usage, or supplies that either) Tj
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(generally accepted standards) Tj
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(of) Tj
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(medical practice.) Tj
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(When possible, we develop written criteria \(called) Tj
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(medical criteria\) concerning services or supplies that we consider to be investigational.) Tj
ET
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(medical) Tj
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(assessments.) Tj
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(and our members.) Tj
ET
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(We do this so that you and your providers will know in advance, when possible, what) Tj
ET
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(we will pay for.) Tj
ET
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/F2 10 Tf
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(If a service or supply is considered investigational according to one of our published) Tj
ET
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/F2 10 Tf
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(medical) Tj
ET
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(criteria policies, we will not pay for it.) Tj
ET
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(addressed by one of our published medical) Tj
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(x) Tj
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(x) Tj
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(The scientific evidence must permit conclusions concerning the effect of the technology on health) Tj
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(outcomes;) Tj
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(x) Tj
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(The technology must improve the net health outcome;) Tj
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(x) Tj
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(The technology must be as beneficial as any established alternatives; and,) Tj
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(x) Tj
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(The improvement must be attainable outside the investigational setting.) Tj
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/F2 10 Tf
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(It is important for you to remember that when we make determinations about the investigational nature of) Tj
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(service or supply.) Tj
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(physician and other medical) Tj
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(providers.) Tj
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(Medical Emergency:) Tj
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(permanent lack of function of any bodily organ or part.) Tj
ET
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(Medically Necessary or Medical Necessity:) Tj
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(We use these terms to help us determine whether a) Tj
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(particular service or supply will be covered.) Tj
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(We do this so that you and) Tj
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(x) Tj
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(Member:) Tj
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(Statistical Manual of Mental Disorders.) Tj
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(Out-of-Network Provider:) Tj
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(Outpatient:) Tj
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(x) Tj
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(as amended from time to time.) Tj
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(documents consist of the following:) Tj
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