Download 2016 Traditional Care Network (TCN) Benefits at a glance for

2016 Traditional Care Network (TCN)
Benefits at a glance for General Motors UAW Trust members
Group Number: 71436
Contents
Traditional Care Network ................................................................ 2
Cost sharing summary and benefits at a glance.......................... 4
Understanding important terms ..................................................... 5
Explanation of benefits.................................................................. 14
Claims questions and appeals..................................................... 16
Contact information ......................................................Back cover
1
Traditional Care Network
You have many options when it comes to choosing health care. Thank you for choosing the Blues.
ms/definitions
Hospital care
Call/nursing telephone support
Hospital and other services
Alternatives to hospital care
Plan benefits
Ready to join
Maternity care
We offer:
• Traditional Care Network (TCN) health plan (for members under and over 65 years old)
Who can join
• Medicare Advantage health plan (for members enrolled in Medicare who are at least 65 or deemed
eligible for Medicare)
and other services
es to hospital care
nal medicare
Plan benefits
Ready to join
Maternity care
Other services
Mental health and substance abuse
treatment
Questions
Leaving the hospital
DME
Organ transp
• Blue Care Network and Blue Care Network Advantage health plans (in Michigan only)
Who can join
Member
Physicians/Providers
As a member of the UAW Retiree Medical Benefits Trust, you can choose one of several Blue plans that
meet your needs and those of your family. Each plan offers you the same great benefits that come with
being a Blue Cross Blue Shield of Michigan member.
he hospital
Questions
DME
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Physicians/Providers
Call/nursing telephone support
Eye car
Organ transplant
Member
Missouri
Customer service
There is always extra value when you choose Blue. With every Blue card, you receive additional support.
Some of the programs we offer members include:
Important terms/definitions
com/online/live
n drugs
MyBlue Medicare Magazine
Deductible, coinsurance and dollar
maximums
Important terms/definitions
Hospital care
Physician office services
Reasons to join
Hospital care
Outpatient diagnostic services
Hospital and other services
Alternatives to hospital care
Surgical services
Call/nursing telephone support
Beyond original medicare
Tobacco
cessation
Surgical
services
heart failure or COPD
SilverSneakers
Facing a complex medical condition
hearing
Hospital and other services
Alternatives to hospital care
care
PlanEye
benefits
Ready to join
Other services
Emergency
hearing services
Shot
Who can join
Pneumonia
Customer service
Mental health and substance abuse
Leaving the hospital
treatment
Coping
with heart failure or COPD
Facing a complex medical condition
Questions
DME
Where am i covered
Who can join
Research monitors
Case Management solutions that assist with medical issues, give you access to
experts who can coordinate treatments, and provide
guidance and support.
Questions
Other services
Mental health and substance abuse
Leaving the hospital
DME
treatment
You can call 1-800-845-5982 for direction.
Shot
Beyond original medicare
Ready to join
Our tobacco cessation program that teaches you self-management and coping skills
for smoking intervention and cessation. You can call 1-800-775-2583 to get started.
Missouri
s
diagnostic
services
Plan benefits
Where am i covered
Pneumonia
Preventive care
Member
Physicians/Providers
Prescription drugs
Research monitors
Deductible, coinsurance and dollar
maximums
Reasons to join
Physicians/Providers
Online health resources at bcbsm.com that include more than 90,000 medically
reviewed resources in a number of formats, such as:
Missouri
SilverSneakers
Internet/bcbsm.com/online/live
coaching
Preventive care
Prescription drugs
– libraries, encyclopedias and directories
MyBlue Medicare Magazine
Physician office services
Outpatient diagnostic services
Deductible, coinsurance and dollar
Surgical servicesmaximums
Customer ser
Reasons to join
hearing
Shot
– videos, calculators, podcasts, and animations
Pneumonia
Missouri
– decision making guides and interactive quizzes
Internet/bcbsm.com/online/live
Everyday savings
coaching
MyBlue Medicare Magazine
Tobacco cessation
Physician office services
Emergency services
Outpatient diagnostic services
Coping with heart failure or COPD
Surgical services
Facing a complex medical condition
hearing
Where am i covered
Research monitors
Shot
Pneum
Healthy Blue XtrasSM and Blue 365® programs offering discounts and exclusive
savings on products, nutrition, travel, recreation, and gym memberships.
2
Everyday savings
Tobacco cessation
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Research monitors
With the Traditional Care Network product (referred to as TCN), you have access to the largest network
of doctors, hospitals, and other health care providers from which to choose within our preferred provider
care organization (PPO).
Our large network gives your family access to thousands of doctors and hospitals. More than likely, any
doctor or hospital you choose will be in the network.
Along with our expansive network, you will usually pay less when you use an in-network provider.
Deductibles, co-insurance, copayments, and overall out of pocket expenses are less when you choose to
use an in-network provider. If you go outside of the vast network of providers however, you will have to pay
more for services.
It’s easy to check to see if your provider is in the network by calling customer service at 1-877-832-2829
or going to bcbsm.com and searching under “Find A Doctor.”
If you ever have any questions about
• your coverage
• bills you may have received
• your explanation of benefits
contact customer service at 1-877-832-2829. You can always find that number on
the back of your card. Customer service representatives will be happy to answer
any questions you may have.
Thank you for being a member of Blue Cross Blue Shield of Michigan. Thank you for
choosing the Traditional Care Network product.
3
Plan benefits
Ready to join
2016
Questions
Benefits at a glance with
cost sharing summary
Maternity care
Who can join
DME
Organ transplant
Monthly contribution and
out-of-pocket expenses
Member
Physicians/Providers
Deductible, coinsurance and dollar
maximums
You pay
In network
Reasons to join
Monthly contribution –
Eye care
The monthly amount you must payMissouri
in order to have coverage
Customer service
for yourself and your dependents
hearing
Deductible – per
calendar year
Surgical services
Shot
Pneumonia
Coinsurance
am i covered
Out‑of‑pocketWhere
maximum
– per calendar
year
Research monitors
Facing a complex medical condition
Combination of deductible and coinsurance
4
Out of network
Individual: $17
Family: $34
Individual: $385
Individual: $1,000
Family: $650
Family: $1,700
10%
30%
Individual: $755
Individual: $3,000
Family: $1,395
Family: $5,550
Understanding important terms
Important terms/definitions
Hospital care
Call/nursing telephone support
Hospital and other services
Alternatives to hospital care
Beyond original medicare
Other services
Mental health and substance abuse
treatment
Leaving the hospital
Plan benefits
Ready to join
Insurance pays 100%
Out-of-pocket
maximum met
Questions
DME
$$$
Coinsurance
SilverSneakers
Preventive care
Deductible met
Internet/bcbsm.com/online/live
coaching
MyBlue Medicare Magazine
Prescription drugs
(you andDeductible,
insurance
coinsurance and dollar
maximums
share cost)
Reasons to join
$$
Physician office services
Outpatient diagnostic services
Surgical services
hearing
Deductible
(you pay)
Everyday savings
Tobacco cessation
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Deductible — The amount you must pay toward covered medical services within a calendar year before
the Plan begins to pay. This does not apply to services that require a copay.
Coinsurance — The percentage you pay for covered services after you have met your deductible.
Out-of-pocket maximum — The total amount you will pay in a calendar year. It is a combination of the
deductible and coinsurance. Once paid, all covered services are paid at 100% for the rest of the calendar year.
Copayment (copay) — A fixed amount you pay to receive a medical service, usually at the time the
service is performed (office visits, emergency room, urgent care). Note that the copayment does not
go toward paying the deductible, coinsurance or out-of-pocket maximum. Copays are separate and
continue even after your out-of-pocket maximums are met.
In-network providers — Providers (i.e., hospitals and doctors, etc.) that sign a contract agreeing
to accept the allowed amount for a service as payment in full so that members will not be billed for the balance.
Out-of-network providers — Providers (i.e., hospital and doctors, etc.) that have not signed
a contract with the Blues to accept the approved amount and may bill for balances.
Out-of-network providers may result in higher out-of-pocket costs.
5
Who can join
2016 Benefits at a glance
Mental health and substance abuse
treatment
Leaving the hospital
Questions
DME
Organ transplant
Member
You pay
Physicians/Providers
Preventive services
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
In network
Out of network
Covered – 100%
Covered – subject
to deductible and
coinsurance
Customer service
Reasons to join
Pap Smear Screening — one per calendar year
Missouri
Mammography Screening
Routine and high-risk mammogram screening in
accordance with Outpatient
guidelines
established
by the American
Physician office services
diagnostic services
Surgical services
hearing
Cancer Society – one routine exam per calendar year
beginning at age 40. Under age 40, one per calendar year,
if high-risk factors are present
Covered – 100%
Prostate Specific Antigen (PSA) Screening
Screening test for asymptomatic males age 40 and older
whenservices
performed in
accordance
guidelines
established
Emergency
Coping
with heart failure or COPD with
Facing
a complex medical condiWhere am i covered
tion
by the American Cancer Society – one
per calendar year
Covered – 100%
Shot
Covered – subject
to deductible and
coinsurance
Pneumonia
Research monitors
Covered – subject
to deductible and
coinsurance
Early Detection Screening Tests
Early detection screening for colon and rectal cancers
when performed in accordance with guidelines
established by the American Cancer Society.
Barium Enema X-ray — one every 5 years age 50 and over
(or at any age if risk factors are present); or
Colonoscopy — one every 10 years age 50 and over
(or at any age if risk factors are present); or
Covered – 100%
Not covered
Hepatitis C (HCV) Screening
For enrollees who are at risk or when signs or symptoms
are present which may indicate a Hepatitis C infection
Covered – 100%
Covered – subject
to deductible and
coinsurance
Well Baby – Six visits up to age 2
Covered – 100%
Not covered
Immunizations — age and frequency limitations for
selected medically recognized immunizations at doctor’s
office, retail health clinic, and certain immunizations at
a pharmacy.
Covered – 100%
Sigmoidoscopy — one every five years age 50 and over
(or at any age if risk factors are present)
Fecal Occult Blood Test — one per calendar year
beginning at age 50
Total serum cholesterol with low density lipoprotein (LDL) —
one test every 5 years beginning at age 20
Bone Marrow Screening
6
Not covered
Not covered
Not covered
Eye care
Physicians/Providers
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Eye care
Missouri
You pay
Physician office services
Call/nursing telephone support
Hospital and other services
Outpatienttodiagnostic
services
Alternatives
hospital care
Physician office services
Plan benefits
Non-Medicare members —
Covered with $25
Shot
copayment for
the first sixPneumonia
office visitsWho
tocanajoinPrimary
Care Physician, per year
per member. 100% member
Where am i covered
copayment for specialists
Research monitors
and subsequent office visits
at a discounted rate
hearing
Office Visits — not subject to deductibles or
Coping with heart failure or COPD
Facing a complex medical condiout-of-pocket maximums
Questions
tion
Leaving the hospital
Out of network
Ready to join
Surgical services
Emergency services
Mental health and substance abuse
treatment
In network
Customer service
DME
Maternity care
Not covered
Organ transplant
Member
Physicians/Providers
Medicare
members
have coverage through
Medicare.
Office Consultation & Outpatient Consultation — not
subject to deductibles or out-of-pocket maximums
Covered at a 100%
member copayment for
Missouriprocedure codes
certain
Customer service
allowed at discounted rate
Not covered
Retail Health Clinics
Covered – $50 copayment
Not covered
Preventive care
Physician office services
Prescription drugs
Outpatient diagnostic services
Deductible, coinsurance and dollar
maximums
Surgical services
Reasons to join
Eye care
hearing
Shot
Emergency medical care
Hospital
Room
Emergency services Emergency
Coping with
heart failure or COPD
Facing a complex medical condiWhere am i covered
tion
Services rendered in the emergency room of a hospital
for initial examination and treatment of condition resulting
from accidental injury or qualifying medical emergency
are covered. Medical emergencies will be considered to
exist only if medical treatment is secured within 72 hours
after the onset of condition.
Physician
Qualified Medical Emergency & First Aid Services
Initial examination and treatment of a qualifying condition
resulting from accidental injury or qualifying medical
emergency. Medical emergencies will be considered to
exist only if medical treatment is secured within 72 hours
after the onset of condition.
Urgent Care Centers
Ground Ambulance — medically necessary transport
Air/Water Ambulance
Covers one-way transport from the scene of an emergency
incident to the nearest available facility qualified to treat the
patient, or transporting a patient one-way or round-trip from
home to the nearest available facility qualified to treat the
patient. Medical emergency/accidental injury patients are
provided one-way transportation from home to the facility.
Home bound patients are provided round trip transportation
from home to the facility and back when medically
necessary and when other means of transportation could
not be used without endangering the patient’s health.
Medical Emergency/Accidental Injury: Follow-Up Care
Pneumonia
You pay
In network
Out of network
Research monitors
Covered – $125
copayment waived
if admitted
Covered – $125
copayment waived
if admitted
Covered – 100%
Covered – 100%
Covered – $50 copayment
Covered – subject
to deductible and
coinsurance
Not covered
Covered – subject
to deductible and
coinsurance
Covered – 100% up to the
allowed amount
Covered – 100% up to the
allowed amount
Not covered
Not covered
7
ice
Member
2016 Benefits at a glance
Physicians/Providers
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Diagnostic services
Eye care
Missouri
Customer service
Outpatient Magnetic
Imaging (MRI),
Surgical services Resonance
hearing
Magnetic Resonance Angiography (MRA)
Use of MRI for diagnostic examination for all body Shot
parts
when ordered by a physician and performed on approved
equipment. Must be performed at approved facilities.
You pay
In network
Out of network
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Outpatient diagnostic services
Preauthorization
may
Facing
a complexbe
medicalrequired.
condiWhere am i covered
Coping with heart failure or COPD
tion
Other Outpatient Diagnostic Tests, X-rays, Laboratory
& Pathology, PET, CAT Scans and Nuclear Medicine
Pneumonia
Research monitors
Preauthorization may be required.
Radiation Therapy — for the diagnosis of condition,
disease or injury.
Preauthorization may be required.
Maternity services
provided by a physician
You pay
In network
Out of network
Pre-Natal and Post-Natal Care
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Delivery and Nursery Care
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Maternity care
Organ transplant
Abortions — must be medically necessary.
For medically induced abortion by oral ingestion of
medication when medically necessary
Certified Nurse Midwife
Eye care
For a given
uncomplicated pregnancy, reimbursement
for such care would be to the physician or certified nurse
midwife, but not both. Obstetrical services by certified
nurse midwives are limited to basic antepartum care,
normal vaginal deliveries, and postpartum care. Certified
nurse midwives are reimbursed only for deliveries occurring
in the inpatient setting or in a birthing center that is
hospital affiliated, state licensed and accredited and
approved by the carrier.
The certified nurse midwife must be legally qualified and
registered, certified nurse and/or licensed, as applicable,
to perform these health care services.
8
port
e abuse
You pay
Hospital care
Hospital care
Call/nursing telephone support
Hospital and other services
Alternatives to hospital care
In network
Plan benefits
Semi-Private Room, General Nursing Services,
Meals and Special Diets
Mental health and substance abuse
treatment
Leaving the hospital
Who can join
Questions
DME
Inpatient Medical Care
MyBlue Medicare Magazine
Physician office services
Plan benefits
Prescription drugs
Outpatient diagnostic services
Deductible, coinsurance and dollar
maximums
Reasons to join
Emergency services
Surgical services
Questions
Coping with heart failure or COPD
Facing a complex medical condition
Covered – subject
to deductible and
coinsurance
Covered — subject
to deductible and
coinsurance
Research monitors
Hospice Care
(Provider approval required)
Coping with heart failure or COPD
Surgical services
Facing a complex medical condition
Organ transplant
Member
Out of network
Not covered
Limited to 100 days per
benefit period. Renewable
after 60 days of continuous
non-confinement.
Covered — subject
to deductible and
coinsurance
Not covered
Limited to 2 days of
hospice care for each
remaining inpatient
hospital day. Lifetime
maximum of 210 days.
Covered — subject
to deductible and
coinsurance
Not covered
Eye care
Missouri
Outpatient diagnostic services
You pay
In network
DME
Reasons to join
Pneumonia
Maternity care
Where am i covered
Physicians/Providers
Deductible, coinsurance and dollar
maximums
Eye care
Customer service
Shot
Ready to join
Skilled Nursing Facility
(Must be an approved BCBS Skilled Nursing Facility)
Prescription drugs
Covered – subject
to deductible and
coinsurance
Organ transplant
hearing
Who can join
Leaving the hospital
Covered – subject
to deductible and
coinsurance
Missouri
Ambulatory Surgical Centers
(Facility must satisfy Program requirements and be an
approved facility)
Tobacco cessation
Covered – subject
to deductible and
coinsurance
Physicians/Providers
Alternatives to hospital care
Hospital and other services
Alternatives to hospital care
Covered – subject
to deductible and
coinsurance
Member
Chemotherapy
Coverage is provided for treatment of malignant disease
and Hodgkins disease, except when the treatment is
considered experimental or investigational.
Preventive care
Covered — subject
to deductible and
coinsurance
Maternity care
Maximum 365 days for each continuous period of
hospital confinement or for successive periods of
confinement separated by less than 60 days.
(Predetermination required for non-Medicare members)
Other services
Out of network
Covered – subject
to deductible and
coinsurance
Ready to join
Customer service
hearing
Where am i covered
Home Health Care
(Facility approval required)
Shot
Pneumonia
Research monitors
Limited to 3 home health
care visits for each
remaining day of the
inpatient hospital benefit
period as long as the
patient is medically eligible.
Not covered
Each visit by member of the
home health care team,
and each home health
aide visit is considered the
equivalent of 1 home visit.
9
s
Organ transplant
2016 Benefits at a glance
Member
Physicians/Providers
Deductible, coinsurance and dollar
maximums
Reasons to join
Eye care
Missouri
You pay
Customer service
Outpatient surgical services
hearing
Surgery — includes
materials, supplies, preoperative and
postoperative care, and suture removal
Shot
Pneumonia
Surgical services
Maternity care
OPD
Voluntary Sterilization — excludes reversal sterilization
Facing a complex medical condition
Where am i covered
Research monitors
In network
Out of network
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
You pay
Human organ transplants
In network
Out of network
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Organ transplant
Specified Organ Transplants
Preauthorization by Human Organ Transplant Program
is required. All members must be enrolled in Case
Management. Must be performed in a Blue
Distinction Center.
Call/nursing telephone support
Eye care
Hospital and other services
Alternatives to hospital care
Plan benefits
Ready to join
Maternity care
Mental health care and
substance abuse treatment
Mental health and substance abuse
treatment
Leaving the hospital
Questions
You pay
Who can join
In network
Out of network
Inpatient:
Up to 45 days treatment
each for psychiatric
and substance abuse
covered — 100% up to the
allowed amount.
DME
Organ transplant
Member
Physicians/Providers
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Eye care
Missouri
Services must be preauthorized by ValueOptions.
For preauthorization, call 1-877-228-3912 (not mandatory
for Medicare enrollees)
Physician office services
Outpatient diagnostic services
Surgical services
hearing
Shot
Emergency services
10
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Outpatient:
Mental Health: Up to 35
visits covered per benefit
period — Visits 1-20: 100%
up to the allowed amount,
Visits 21-35: 75% up to the
allowed amount.
Customer service
Pneumonia
Substance Abuse:
Up to 35 visits per benefit
period covered at 100% up
to the allowed amount.
Research monitors
Inpatient:
Not covered unless
medical emergency
admission.
Outpatient:
Mental Health: Up to 35
visits covered per benefit
period — Visits 1-20: 100%
up to the allowed amount,
Visits 21-35: up to 75% of
the allowed amount.
Substance Abuse:
Up to 35 visits per benefit
period covered at 100% up
to the allowed amount.
e
Hospital care
Call/nursing telephone support
Hospital and other services
Alternatives to hospital care
Plan benefits
Ready to join
Maternity care
Other services
Allergy Testing
Other services
Mental health and substance abuse
treatment
Leaving the hospital
In network
Questions
DME
Allergy Therapy/Serum
Physician office services
Not covered
Not covered
Covered subject
to deductible and
coinsurance
Covered subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Covered – subject
to deductible and
coinsurance
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Outpatient diagnostic services
Surgical services
Missouri
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Durable Medical Equipment*
Prosthetic and Orthotic Appliances
Hair Pieces and Wigs — Wigs and appropriate related
supplies (stand and tape) are covered for any age for
an individual who is suffering hair loss from the effects of
chemotherapy, radiation therapy or other treatments for
cancer. For the initial purchase of wig and related supplies,
the maximum benefit is $250. Thereafter, the maximum
annual benefit is $125.
Prosthetic and Orthotic: Jaw Motion Rehabilitation
(Jaw motion rehabilitation system and related items)
Diabetes Education
Covers comprehensive American Diabetes Associationapproved education classes for newly-diagnosed or
uncontrolled diabetics.
Cardiac Rehabilitation – Only Phases I and II are covered
Must begin within 3 months of a cardiac event and be
completed within 6 months.
Customer service
Pneumonia
Limited to 60 combined
visits per calendar year, per
condition.
Where am i covered
Outpatient Physical, Speech and
Occupational Therapy
(medical necessity required)
Eye care
Covered — subject
to deductible and
coinsurance
hearing
Shot
Tobacco cessation
Organ transplant
Physicians/Providers
Excludes adjustment manipulation and initial office visit
MyBlue Medicare Magazine
Out of network
Member
Chiropractic Care
Emergency first aid and diagnostic x-ray of the spine only.
Preventive care
You pay
Who can join
Research monitors
Services are covered
when performed in the
outpatient department of
the hospital or approved
freestanding facility.
Therapy is also covered
when provided by an
in-network independent
physical therapist, an
independent occupational
therapist, or speech and
language pathologist.
Not covered
Covered — 100%
Not covered
Covered — 100%
Prosthetic & Orthotic
appliances are not
covered with the
exception of wigs
Not covered
Not covered
Covered — 100%
Not covered
Up to 36 sessions
(3 sessions per week for
12 weeks) covered at 100%
up to the allowed amount
Not covered
*Durable Medical Equipment — Subject to deductible and coinsurance when processed as part of inpatient services or office services.
11
nd dollar
condi-
2016 Benefits at a glance
DME
Organ transplant
Member
Physicians/Providers
Reasons to join
Eye care
Hearing care
Missouri
must be a participating provider
hearing
Audiometric exam — once every 36 months
Shot
Pneumonia
Hearing aid evaluation — once every 36 months
Where am i covered
You pay
Customer service
Research monitors
Maternity care
In network
100% up to the
allowed amount
100% up to the
allowed amount
Out of network
Not covered
Not covered
100% up to the
standard hearing aid
allowance
Not covered
Binaural hearing aids for children 19 and under — once
every 36 months
100% up to the
allowed amount
Not covered
Hearing
Organ transplant aid conformity test — once every 36 months
100% up to the
allowed amount
Not covered
Ordering and fitting the hearing aid (one monaural)
standard or digital — every 36 months
Vision care
Eye care
medical coverage
Routine exam
You pay
In network
Out of network
Under the medical
coverage, one routine
vision exam covered with
a $25 copayment, once
every 24 months.
Under the medical
coverage, one routine
vision exam covered with
a $25 copayment, once
every 24 months.
Routine exams, frames, lenses and additional services -- Contact Davis Vision at 1-888-234-5164.
12
use
Questions
Leaving the hospital
DME
Organ transplant
Member
Physicians/Providers
Prescription drugs
You pay
Coverage administered by Express Scripts 866-662-0274
Prescription drugs
Deductible, coinsurance and dollar
maximums
Retail
(One-Month Supply)
Mail Order
Outpatient diagnostic services
Surgical services
(90-Day Supply)
Tier 1: Generic $12
Reasons to join
Missouri
Customer service
Tier 3: Non-preferred Brand $100
Tier 1: Generic $24
Tier 2: Preferred Brand $80
hearing
Tier 3: Non-preferred Brand $200
Shot
Coping with heart failure or COPD
Facing a complex medical condition
Eye care
Tier 2: Preferred Brand $40
Where am i covered
Prescription Drug Categories
Pneumonia
Research monitors
Tier 1: Generic Medications (Equivalents or Alternatives)
Important terms/definitions
Tier
(Single
Source,
Sensitive
Drug Classes)
Hospital2:
care Brand Medications
Call/nursing telephone support
Hospital
and other services Preferred
Plan benefitsBrand, andReady
to join
Alternatives to hospital care
Tier 3: Brand Medications (Multi-Source or Non-Preferred Brand)
Who can join
Beyond original medicare
Other services
Mental health and substance abuse
treatment
Leaving the hospital
Questions
DME
M
Physicians/Providers
SilverSneakers
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Missouri
Internet/bcbsm.com/online/live
coaching
MyBlue Medicare Magazine
Physician office services
Outpatient diagnostic services
Surgical services
hearing
Shot
Everyday savings
Tobacco cessation
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Pneumonia
Research monitors
13
“EOB” stands for Explanation of Benefits
As a member of the Traditional Care Network plan, once you have services performed, you will receive
an Explanation of Benefits, or EOB. The EOB will show you:
• What services you had and what the provider billed
• What your Plan paid and any Blue Cross discounts that were applied
• The amount you may owe through deductibles, coinsurance or copayments
• Any non-covered services that were not payable through your benefit plan
Reviewing your EOB statements is a good way to keep track of your medical care.
EOB Statement Details
1
Identifies who this EOB
statement is for.
2
Summarizes claims by doctor,
hospital, or other health care
provider as follows:
A
The amount submitted to
Blue Cross on the claim.
B
What you saved by being a
Blue Cross member.
C
What Blue Cross paid.
D
Amounts any other
insurance(s) paid.
E
What you pay. You may have
already paid or may still owe
this amount. You should never
be asked to pay more than
this amount.
3
Shows the balances to date
for deductibles and out-ofpocket maximums for your
current benefit period.
4
Important information about
your coverage, tips to lower
health care costs, and ways to
improve overall health.
5
Customer Service information
if you have questions about
something on your statement.
14
5
1
2
A
B
C
D
E
3
4
The statement shown is general and for illustrative purposes only.
Your actual statement may look slightly different depending on your
benefit plan.
6
Detailed information about
each claim we processed.
The sum of all claims in this
section for the same provider
should match the numbers in
the Claim Summary section.
F
Information your provider puts
on the claim to identify the
medical service you received.
G
The unique number Blue Cross
assigns to a claim. You can
reference this number if you
need to call us about this claim.
Important terms/definitions
Hospital care
6
F
G
Page 2 of your statement shows your appeal rights and what you
can do if you disagree with any of the benefit decisions made for a
claim. You can also find definitions for terms used on the statement.
Call/nursing telephone support
Hospital and other services
Alternatives to hospital care
Plan benefits
Ready to join
Who
Beyond original medicare
Other services
Mental health and substance abuse
treatment
Leaving the hospital
Questions
DME
Physicians/Provi
SilverSneakers
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Online EOBs
Internet/bcbsm.com/online/live
coaching
Everyday savings
Missouri
Log in at bcbsm.com if you want to view recent claims, deductibles, coinsurance
MyBlue Medicare Magazine
Physician
office services
Outpatient
diagnostic services
Surgical services
hearing
balances,
and other
information.
It’s
easy:
1.
Go to bcbsm.com and follow steps to create a login account.
2.
After logging in, select Claims in the blue bar near the top.
3.Tobacco
Click
on Explanation
of Benefits
statements.
cessation
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Shot
Where am i covered
Research m
Help us prevent fraud
Call/nursing telephone support
Checking to make sure you actually received services as shown on the EOB
helps us prevent error and fraud. Call your customer service number 1-877-832-2829,
if you have questions about a claim or EOB.
Hospital and other services
Alternatives to hospital care
Plan benefits
Ready to join
Maternity care
Who can join
Mental health and substance abuse
treatment
Leaving the hospital
Questions
DME
15
Claim questions and appeals
1
To confirm you are paying the right
amount, compare the EOB and the
provider bill side-by-side. Match the
service dates and the amounts. If they
match, pay the provider that amount
and file the EOB for your records.
16
After your claims are submitted to BCBS by your providers, you will receive an Explanation of
Benefits. In addition, you will most likely receive a billing statement from your provider, showing any
outstanding balances you may owe.
2
3
If the amounts do not match,
or if you have questions,
call customer service at
1-877-832-2829, as shown on the
back of your BCBS identification card.
A BCBS representative will be happy
to review the EOB statement and
answer your questions.
If you are not satisfied with the response
or outcome from customer service,
you may file an appeal with BCBS by
completing an Auto/Inquiry Appeal form.
The BCBS customer service representative
can help you obtain the form.
4
5
Once you receive the form, make sure to
attach an explanation of your concern and
copies of the statements in question. Check
the Appeal Box on the form and mail to:
If the issue remains unresolved,
you may file an appeal with the UAW Trust.
Please see your Summary Plan for details.
Auto National Appeal Unit
600 Lafayette East – Mail Code #2004
Detroit, Michigan 48226-2998
17
Contact information
Blue Cross Blue Shield of Michigan
ValueOptions – Help Line
Hospital, Surgical/Medical Services
For questions on benefits, claims or
how to locate providers, 8 a. m. - 8 p.m.
Eastern time, Monday – Friday
Precertification — Mental Health
and Substance Abuse
(required for non-Medicare members only)
1-877-228-3912
1-877-832-2829
Mailing Address (for claim inquiries):
Blue Card Access —
National Provider Network
UAW Auto Retiree Service Center
Information on participating network
providers at home and while traveling
P.O. Box 311088
Detroit, Michigan 48231
1-800-810-2583
Case Management
Coordination of health care
Express Scripts (formerly Medco Health)
1-800-845-5982
Mail Order and Retail (Drug Stores)
Prescription drug questions
1-866-662-0274
Retiree Health Care Connect
The UAW Trust eligibility and call center
Eligibility, membership, address changes,
and ID card requests.
Delta Dental
1-800-524-0149
1-866-637-7555
Davis Vision
Tobacco Cessation
1-888-234-5164
1-800-775-2583
Medicare
Veterans Health Administration
medicare.gov
va.gov/health
1-800-633-4227
1-877-222-8387
UAW Retiree Medical Benefits Trust
uawtrust.org
Blue Cross Blue Shield of Michigan
is proudly represented by the UAW
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