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Microsoft word - wmhip flexible blue 2, rx6, dental 1 pkg 038,039

Flexible Blue 2, RX6, Dental 1
Benefits-at-a-Glance
Western Michigan Health Insurance Pool
Group Number: 71565
Package Code(s):038, 039
Section Code(s):3000, 3100

In-Network
Out-of-Network
Deductible, Copays/Coinsurance and Dollar Maximums
Deductible - per calendar year
(The family deductible can be met by one person on
contracts of 2 or more people)

Copays/Coinsurance

20%
Note: Services without a network are
covered at the in-network level.
Out-of-Pocket Maximum
Lifetime Maximum
Preventive Services
Health Maintenance Exam - one per calendar year Routine Physical Related Test - X-Rays, EKG and lab procedures performed as part of the health maintenance exam Annual Gynecological Exam - one per calendar year, in addition to health maintenance exam Pap Smear Screening - one per calendar year Mammography Screening - one per calendar year Prostate Specific Antigen (PSA) Screening - one per calendar year Endoscopic Exams - one per calendar year Visits beyond 47 months are limited to one per member per calendar year under the health maintenance exam benefit. Physician Office Services
Emergency Medical Care
Qualified medical emergency Non-Emergency use of the Emergency Room Ambulance Services - Medically Necessary Transport Diagnostic and Therapeutic Services
MRI,MRA, PET and CAT Scans and Nuclear Medicine Diagnostic Tests, X-rays, Laboratory & Pathology Maternity Services Provided by a Physician
Hospital Care
Semi-Private Room, Inpatient Physician Care, General Nursing Care, Hospital Services and Supplies Inpatient Medical Care Alternatives to Hospital Care
Surgical Services
Surgery (includes related surgical services) excludes reversal sterilization Sterilization - females only; Human Organ Transplants
Specified Organ Transplants in designated facilities Not covered except in designated facilities only, when coordinated through BCBSM Human Organ Transplant Program (800-242-3504) Kidney, Cornea, Bone Marrow and Skin Behavioral Health and Substance Abuse Services
Inpatient Behavioral Health and Substance Abuse Care Outpatient Behavioral Health and Substance Abuse Care Other Services
24 visit maximum per calendar year Durable Medical Equipment Therapy Services
Physical, Occupational and Speech Therapy Note: The following services require preapproval: Inpatient Care, select Radiology Services, Inpatient Behavioral Health and Substance Abuse Care, and Skilled Nursing. Prescription Drugs
Deductible - per calendar year
(The family deductible can be met by one person on
contracts of 2 or more people)

Out of Pocket Maximum

Retail- 30 day supply
$ 0 copay – OTC drugs (Only – Zyrtec, Zyrtec D, Prilosec, Claritin, Children’s Claritin, Claritin RediTabs and Claritin-D) $10 copay for generic drugs $40 copay for brand name drugs Mail Order- 90 day supply
$ 0 copay – OTC drugs (Only – Zyrtec, Zyrtec D, Prilosec, Claritin, Children’s Claritin, Claritin RediTabs and Claritin-D) $20 copay for generic drugs $80 copay for brand name drugs Oral and Injectable Contraceptives
Covered - 100% for generic drugs; brand name drugs are subject to the applicable Additional Services
Covered– limited to 12 doses per month Diabetic Supplies
The information in this document is based on BCBSM’s current interpretation of the Patient Protection and Affordable Care Act (PPACA). Interpretations of PPACA vary and the federal government continues to issue guidance on how PPACA should be interpreted and applied. Efforts will be made to update this document as more information about PPACA becomes available. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details. This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM’s approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Traditional Plus Dental Coverage
Western Michigan Health Insurance Pool
Class I Services
Periodic Oral Exams
Covered - 100%, once per quadrant per lifetime, through age 18 Covered - 100%, once per tooth every 36 months, through age 19 Class II Services
Covered - 80% after deductible, once every 24 months Covered - 80% after deductible, once every 12 months Inlays, Onlays and Crowns - permanent teeth Covered - 80% after deductible, once every 60 months, payable for members age 12 and older Recementing of Crowns, Inlays, Onlays and Bridges Covered - 80% after deductible, three per calendar year Covered - 80% after deductible, once per tooth, per lifetime Covered - 80% after deductible, once every 24 months Covered - 80% after deductible, up to five times in a 60-month period Covered - 80% after deductible, once every 12 months Covered - 80% after deductible, when medically necessary and with oral or dental surgery Oral Surgery including extractions (excludes removal of impacted teeth) Relining or Rebasing of Partials or Dentures Covered - 80% after deductible, once every 36 months per arch Covered - 80% after deductible, once every 36 months per arch Class III Services
Removal Dentures - Complete and Partials Covered - 50% after deductible, once every 60 months Covered - 50% after deductible, once every 60 months for members age 16 and older Covered - 50% after deductible - Once per tooth in a member lifetime when implant placement is for teeth numbered 2 through 15 and 18 through 31, age 16 or older Class IV Services – Orthodontic services for dependents No age limits
Habit Breaking Appliances
Benefit Period, Copays and Dollar Maximums
Benefit Period
Deductible
$50 Individual, No Deductible Family – Applies to Class II & Class III & Class IV Member Coinsurance
Covered 0% for Class I services, Covered 20% for Class II services, Covered 50% for Class III services and Covered 50% for Class IV services Dollar Maximums - Annual Maximum
$1000 per member for covered Class II & III services With Traditional Plus Dental, members can choose any licensed dentist anywhere. However, they’ll save the most money when they choose a dentist who is a member of the Dental Network of America (DNoA) Preferred Network of PPO dentists. DNoA Preferred Network – Blue Dental members have unmatched access to PPO dentists through the DNoA Preferred Network, which offers nearly 200,000 dentist access points*
nationwide. DNoA Preferred Network dentists agree to accept our approved amount as payment in full and participate on all claims. Members also receive discounts on noncovered services
when they use PPO dentists. To find a DNoA Preferred Network dentist near you, please visit
BCBSM.com/bluedental or call 1-888-826-8152.
* A dentist access point is any place a member can see a dentist to receive high-quality dental care. For example, one dentist practicing in two locations would be two access points. Blue Par SelectSM arrangement – Most dentists accept our Blue Par Select arrangement, which means they participate with the Blues on a “per claim” basis. Members should ask their dentists
if they participate with BCBSM before every treatment. Blue Par Select dentists accept our approved amount as full payment for covered services — members pay only applicable copays and
deductibles, along with any fees for noncovered services. To find a dentist who may participate with BCBSM, please visit BCBSM.com/bluedental.
Note: Members who go to nonparticipating dentists may be billed for any difference between our approved amount and the dentist’s charge

Source: http://www.dkschools.org/wp-content/uploads/2012/02/WMHIP-Flexible-Blue-2-RX6-Dental-1-Pkg-038039_020613.pdf

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