Certificate and Rider Description
#67800-663

Community Blue PPO Certificates and Riders
Certificate/Rider Number
Benefit Description
Community Blue Group Benefits Certificate 6225
Provides hospital, medical-surgical, and selected preventive services under a Preferred Provider Organization (PPO) arrangement, subject to a $5 million lifetime maximum. Innetwork, members have a $10 fixed co-pay for selected office services, a $50 co-pay for emergency room visits and a 50% co-pay for all mental health care, substance abuse treatment and private duty nursing. When members choose to go outside the network, there is a $250 per member, $500 family deductible, a 20% out-of-network co-pay, a $50 fixed co-pay for emergency room and a 50% co-pay for all mental health care, substance abuse treatment and private duty nursing. Preventive care is not covered out-of-network.
Rider ASFP 5821 Ambulatory Surgical Facility Program
Extends benefits to cover outpatient surgery performed in Blue Cross Blue Shield-approved freestanding facilities.
Rider BCP PPO 7822 Blue Card PPO Program
Clarifies how health care services received by BCBSM members in other states are processed through the Blue Card PPO Program.
Rider BMT 4398 Bone Manow Transplants
Extends benefits to cover outpatient surgery performed in Blue Cross Blue Shield-approved freestanding facilities.
Rider CB-MH 20% 5811 Mental Health/Substance Abuse Treatment co-pay Requirement
Decreases the co-pay for mental health care and substance abuse treatment from 50% to 20%.
Rider CB-PCB

 6603
 Preventative Care Benefit
Adds screening benefits for the following laboratory and radiology procedures:
  • Chemical profile (80002, 80012, 80016, 80018, 80019)
  • Complete blood count (85021.85031 )
  • Urinalysis (81000, 81002)
  • Chest x-ray (71020)
  • EKG (93000,93010)
The above procedures are added as preventative care benefits and are subject to the following criteria:
  • One of each test per member, per calendar year:
  • No age restrictions;
  • When performed as routine screening, these benefits will be subject to the
    annual $250 preventative care benefits maximum (unless the member is also     enrolled in rider CB-PCM which removes the $250 maximum).
  • Co-pays and deductibles do not apply to any of the preventative care benefits;
  • Services must be performed by a panel provider:
  • Benefits will "not" be covered when referred to a non-panel provider.
Rider CB-PCM 5812
 Preventive Care Maximum
Removes the $250 annual maximum for covered preventive services. All age and frequency limitations remain the same.
Rider CNM
 6600
 Certified Nurse Midwife
Allows for specific services provided by a Certified Nurse Midwife including normal vaginal delivery in an inpatient hospital setting or Blue Cross Blue Shield approved birthing center. Pre-and post-natal care and PAP smear during the six week visit are also covered when these services are a part of the member's coverage.
Rider CNP 3687
 Certified Nurse Practitioner
Allows payment to participating Certified Nurse Practitioners for services covered by the member's group health plan when provided in any location except a hospital inpatient setting.
Rider CRNA
 5385
 Certified Registered Nurse Anesthetist
Includes certified registered nurse anesthetists (CRNA) as professional providers and pays them directly for covered anesthesia services.
Rider DC 4656 Dependent Continuation
Allows members to continue group coverage for dependent children between the ages of 19-25 when eligibility requirements are met.
Rider EBMT 4397 Experimental Bone Marrow Transplants
Establishes the criteria and clarifies which conditions are payable for experimental bone marrow transplants. Donors must meet genetic marker criteria. Requires prior approval by Blue Cross Blue Shield.
Rider ECIP 5216 Extended Coverage for Inpatient Psychologists' Services
Allows fully licensed psychologists with hospital privileges to receive direct reimbursement for certain covered inpatient mental health care services.
Rider ESRD 5423 End Stage Renal Disease
Clarifies when Blue Cross Blue Shield benefits for hemodialysis and peritoneal dialysis are available for members with End Stage Renal Disease (ESRD).
Rider GCO 9770 Group Continuation Option
Clarifies a member's eligibility rights to continue group coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA).
Rider GLE-1 9930 General Limitations and Exclusions
Excludes benefits for services, care, devices, or supplies considered experimental or research in nature.
Rider HMN 5227 Hospital Medical Necessity
Establishes the criteria Blue Cross Blue Shield uses to define hospital medical necessity.
Rider ICMP 6003 Individual Case Management Program
Adds benefits for services provided on an exception basis to eligible members who, along with their physician. agree to treatment under an Alternative Benefit Plan intended to provide quality care under lower-cost alternatives.
Rider MLOS 5819 Maternity Length of Stay
Clarifies federal law regarding hospital lengths of stay for mothers or newborn children following childbirth.
Rider PTFS 7292 Physical Therapy in Freestanding Facilities
Allows payable physical therapy, occupational or functional therapy and speech therapy services to be covered in a participating freestanding facility.
Rider PTS 6217 Physical Therapy Services
Allows payment to independent physical therapists for covered physical therapy, occupational or functional therapy and speech therapy.
Rider RAPS 7469 Reimbursement Arrangement for Professional Services
Establishes reimbursement levels for covered professional services.
Rider SD 4651 Sponsored Dependents
Allows members to continue coverage for dependents over 19 years of age who do not meet eligibility requirements for riders K or DC. Member is responsible for the additional charge per sponsored dependent member.
Rider SOT-PE 9909 Specified Organ Transplants in Approved Facilities
Adds transplant benefits for the liver, heart, heart-lung, lung and pancreas in Blue Cross Blue Shield-approved facilities. Requires prior approval by Blue Cross Blue Shield.
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Rider SUBR02 5220 Subrogation
Clarifies Blue Cross Blue Shield's subrogation rights.
Rider XVA-2 5410 Excludes Voluntary Abortions
Excludes benefits for any services related to an abortion except for a spontaneous abortion, or to prevent the death of the woman upon whom the abortion is performed. BCBMS does pay for services or supplies to treat complications resulting from an abortion.
Prescription Drug Coverage Certificates and Riders
Preferred Rx Plan Certificate 3607
Benefit Description Provides benefits for federal- and state-controlled drugs,
injectable insulin. and needles and syringes payable at 100% of the Blue Cross Blue Shield-approved amount. minus the member's co-pay when obtained from a Preferred Rx network provider. Coverage also requires dispensing of generic equivalent drugs. Excludes benefits for contraceptive drugs and drugs dispensed for cosmetic purposes.
Rider PDCR 5162 Drug Co-pay Requirements
$5/$10/$15 Co-Pay (Generic/Formulary/Brand Name)
Rider MOPD 3948 Mail Order Prescription Drugs
Provides benefits for a 90-day supply of medications when prescribed by a physician. Drugs must be dispensed by mail order vendor approved by Blue Cross Blue Shield. Member pays only one co-pay for each 90-day prescription or refill.
This is intended as an easy-to-read reference guide to the certificate and riders that are Part of your Blue Cross Blue Shield health care plan. It is not a contract. An official description of the benefits, limitations and exclusions is contained in applicable Blue Cross Blue Shield certificate and riders. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed according to the laws of the state of Michigan.
Benefit Description for Dearborn Board of Education (#67800-663) 8/15/05