SUMMARY OF BENEFITS
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SUMMARY OF BENEFITS |
| PHYSICIAN OFFICE SERVICES | |
| Routine Office Visits | Covered in full |
| Consulting Specialist Care (when referred) | Covered in full |
| Periodic Physical Exam | Covered in full |
| Routine Pediatric Care | Covered in full |
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| PREVENTIVE SERVICES | |
| Immunizations | Covered in flill |
| Mammography Screening | Covered in full |
| Pap Smears | Covered in full |
| Vasectomies, Tubal Ligations | Covered in full |
| Infertility Counseling/Treatment | 50% copay on all associated costs |
| Invitro fertilization | Not Covered |
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| DIAGNOSTIC and THERAPEUTIC PROCEDURES | |
| Laboratory Tests | Covered in full |
| Diagnostic X-Rays | Covered in full |
| Radiation Therapy | Covered in full |
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| MATERNITY SERVICES PROVIDED BY PHYSICIAN | |
| Prenatal and Postnatal Care | Covered in full |
| Delivery in Hospital and Well-Baby | Covered in full |
| Care in Hospital | |
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| HOSPITAL CARE (Inpatient/Outpatient) | |
| Number of Days of Care | Unlimited |
| Semi-Private Room (Inpatient only), | Covered in full |
| In-Hospital Physician Care, General | |
| Nursing Care, Surgery (including all | |
| related surgical services, anesthesia, | |
| lab, x-rays and drugs) | |
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| EMERGENCY MEDICAL CARE | |
| Rendered In: | |
| Hospital Emergency Room | Covered in full |
| Urgent Care Facility | Covered in full |
| Physician Office | Covered in full |
| Ground Ambulance Services | Covered in full |
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| MENTAL HEALTH CARE | |
| Outpatient Visits | 20 visits per calendar year, covered in full |
| Inpatient Psychiatric Hospital Services | Covered in full up to 45 days per calendar year, renewable after 60 days out |
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| ALCOHOLISM & SUBSTANCE ABUSE SERVICES | |
| Outpatient Visits for crisis intervention and short-term therapy | 20 visits per calendar year, covered in full |
| Intermediate Care | One program per 12 month period, covered in full |
| Detoxification | Covered in full |
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| SKILLED NURSING CARE | |
| Skilled Nursing Facility Care | 730 days per episode of illness |
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| OTHER SERVICES | |
| Prosthetics, Orthotics and Corrective Appliances (when medically necessary. Replacement due to normal wear and tear damage is not a benefit.) |
Covered in full |
| Durable Medical Equipment (when medically necessary) | Covered in full |
| Pregnancy Terminations | Not Covered |
| Allergy Testing, Evaluation and Serum | Covered in full |
| Allergy Injections | Covered in full |
| Hearing Aid Rider | Covers hearing examination & aid once each 36 months |
| Physical Therapy for 60 day period. (condition is subject to significant improvement within 60 days) | Covered in full |
| Prescription Drug Co-pay | See MEBS/Caremark |
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| This is intended to be an easy-to-read summary. It is not a contract. An official description of benefits is contained in applicable Blue Care Network certificates and riders. This coverage is provided pursuant to a contract entered into in the State of Michigan and shall be construed under the jurisdiction and according to the laws of the State of Michigan. Services must be provided or arranged by member's primary care physician or health plan. | |
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| #21282-000 COA (BCN5, SN730, WOC, WERC, FP5, AS5, WMHSA C, HA, P&O5, DME5 and PD5NSC, WP7) | |
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| (11/12/99) | |