Community Blue Plan Summary
(revised 2-18-03)
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Community Blue PPO (Plan 1) |
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In-Network |
Out-of-Network |
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Preventive Services * |
* Unlimited
Preventive Care Benefits, no dollar benefit maximum |
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Health Maintenance Exam |
Covered 100%, one per calendar year,
includes select lab and diagnostic procedures * |
Not Covered |
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Annual Gynecological Exam |
Covered 100%, one per calendar year * |
Not Covered |
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Pap Smear Screening laboratory services only |
Covered 100%, one per calendar year * |
Not Covered |
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Well-Baby and Child Care |
Covered 100% * 6
visits per year through age 1 2
visits per year, age 2 through age 3 1
visit per year, age 4 through 15 |
Not Covered |
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Immunizations |
Covered 100%, NO age limitation |
Not Covered |
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Fecal Occult Blood Screening Complete Blood Count Chemical Profile Flexible Sigmoidoscopy Prostate Specific Antigen (PSA) |
Covered 100%, one per calendar year * |
Not Covered |
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Chest X-ray |
Covered 100%, one per calendar year |
Not Covered |
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Colonoscopy |
Covered 100%, one per calendar year |
Not Covered |
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EKG |
Covered 100%, one per calendar year |
Not Covered |
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Mammography |
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Mammography Screening |
Covered 100% |
Covered 80% after deductible |
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One
per calendar year, no age restrictions |
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Physician Office Services |
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Office Visits |
Covered $10 copay |
Covered 80% after deductible, must be
medically necessary |
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Outpatient and Home Visits |
Covered
$10 copay |
Covered 80% after deductible, must be
medically necessary |
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Office Consultations |
Covered $10 copay |
Covered 80% after deductible, must be
medically necessary |
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Urgent Care |
Covered $10 co-pay |
Covered 80% after deductible, must be
medically necessary |
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Emergency Medical Care |
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Hospital Emergency Room approved diagnosis |
Covered $50 co-pay, waived if admitted or
for an accidental injury (standard
benefit) |
Covered $50 co-pay, waived if admitted or
for an accidental injury |
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Physicians Office approved diagnosis |
Covered 100% |
Covered 100% |
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Community Blue PPO (Plan 1) |
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In-Network |
Out-of-Network |
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Ambulance Services medically necessary |
Covered 90%, after Deductible |
Covered 90% |
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Maternity Services Provided by a Physician |
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Pre-Natal and Post-Natal Care Delivery and Nursery Care Certified Nurse Midwife |
Covered 100% Covered 100% Covered 100% |
Covered- 80% after deductible Covered- 80% after deductible Covered at In Network Level, because no PPO
Network for these providers. However,
must be participating with BCBSM. |
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Abortions (Medically necessary) |
Covered- 100% |
Covered- 80% after deductible |
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Diagnostic Services |
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Laboratory and Pathology Tests |
Covered 100% |
Covered- 80% after deductible |
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Diagnostic Tests and X-rays |
Covered 100% |
Covered 80% after deductible |
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Radiation Therapy |
Covered 100% |
Covered 80% after deductible |
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Hospital Care |
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Semi-Private Room, Inpatient Physician Care,
General Nursing |
Covered 100% |
Covered- 80% after deductible |
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Care, Hospital Services and Supplies |
Unlimited
days |
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Inpatient Consultations |
Covered 100% |
Covered- 80% after deductible |
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Chemotherapy |
Covered 100% |
Covered- 80% after deductible |
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Alternatives to Hospital Care |
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Skilled Nursing Care |
Covered 100% |
Covered at In Network Level, because no PPO
Network, but must be an BCBSM approved
facility, otherwise no payment |
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365
days per calendar year, |
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Hospice Care |
Covered 100% |
Covered 100% |
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Limited
to the lifetime dollar maximum which
is adjusted annually by the state $16,650.85
lifetime maximum, of which $1,137.73 is a physician maximum |
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Home Health Care |
Covered 100% |
Covered 100% |
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Unlimited
visits |
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Ambulatory Surgical Facilities (must be participating with BCBSM.) |
Covered 100% |
Covered at In Network Level, because no PPO
Network, but must be participating with BCBSM. |
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Surgical Services |
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Surgery, including all related surgical
services |
Covered 100% |
Covered- 80% after deductible |
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Human Organ Transplants |
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Specified Organ Transplants in designated
facilities |
Covered 100% |
Covered-
80% after deductible |
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Up to $1 million
maximum per transplant |
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Bone Marrow |
Covered 100% |
Covered- 80% after deductible |
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Kidney, Cornea and Skin |
Covered 100% |
Covered- 80% after deductible |
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Inpatient Mental Health Care and Substance
Abuse Care |
Covered 100% |
Covered 80% after deductible |
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45
days Combined |
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Outpatient Mental Health Care |
Covered - $10 copay 100 visits, In & Out of Panel combined
(non-std. benefit portion) |
Covered- 80%, after deductible (std. benefit) |
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Cover MSWs, CSWs & LLPs |
Covered - $10 copay, processed by Exception
Processing |
Covered - $10 copay processed by Exception
Processing |
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Outpatient Substance Abuse Care |
Covered 100% |
Covered 80%, after deduct. |
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Up
to the state-dollar amount which is adjusted annually |
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Community Blue PPO (Plan 1) |
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In-Network |
Out-of-Network |
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Other Services |
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Allergy Testing and Therapy |
Covered 100% |
Covered 80% after deductible |
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Chiropractic Spinal Manipulation |
Covered 90%, after Deductible |
Covered 80% after deductible |
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Up
to 60 visits per calendar year |
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Outpatient Physical, Speech and Occupational Therapy |
Covered 100% |
Covered 80% after deductible |
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Up
to 80 visits per calendar year |
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Durable Medical Equipment |
Covered 90%, after Deductible |
Covered 90%, after deductible |
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Hearing Care |
Covered 100% when provided by participating
providers. |
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Prosthetic and Orthotic Appliances |
Covered- 90%, after Deductible |
Covered- 90%, after deductible |
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Private Duty Nursing |
Covered 50%, after Deductible |
Covered 50%, after deductible |
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Certified Nurse Practitioner |
Covered Rider CNP $10 copay for office visits |
Covered Rider CNP $10 copay for office visits |
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Individual Case Management |
Covered (ICMP Rider) |
Covered (ICMP Rider) |
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Deductible, Co-pays and Dollar Maximums |
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Deductible |
$50 per member / $100 family Applies only to the following services:
Ambulance, Chiropractic Spinal Manipulation, Durable Medical Equipment,
Prosthetic & Orthotic Appliances, Private Duty Nursing. |
$250 per member, $500 family, Applies to most services |
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Co-pays - Fixed - Percent |
$50 for emergency room visits. Fixed $10 copay for office visits & urgent care
centers. $10 copay for each Outpatient Mental Health
visit. | |