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Health First Medical Summary - BCBS of MT
January 1, 2007 -
December 31, 2007
Medical
Dental
Vision
Vol. Accident
Life/AD&D
Addt'l Life/AD&D
STD
LTD
LTC
Flex
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Information provided is in summary
format. Any difference between the summary provided and
actual contract will be settled in favor of the contract.
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Provider
Network |
Participating Blue Cross/Blue
Shield of Montana |
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Participating
Providers |
Non-Participating
Providers*** |
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Deductible |
$1000
Individual/$2000 Family |
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Plan
Coinsurance, Professional |
70% |
50% |
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Plan Coinsurance,
Facility |
70% |
50% |
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Out-of-Pocket Max* |
$3000 Individual/$6000
Family |
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Lifetime
Maximum
Benefit |
$500,000 for Organ Transplants
$100,000 for Rehabilitative Therapy
$12,000 for Inpatient Chemical Dependency |
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Professional Provider Services
Home and office calls, x-ray, lab, and other
services provided by a Participating Professional
Provider |
70% |
Deductible/50% |
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Preventive
Care
(Birth to 24 months) **
Must be 24 months or older to receive benefits
such as, routine physical exams, routine x-ray and lab
services, immunizations and vaccinations, etc. |
70% |
70% |
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Preventive
Care
(24 months and older) **
Routine physical exams and related tests,
immunizations and vaccinations. |
First $300 of covered charges
related to preventive care covered at 100%, then normal plan provisions |
First $300 of covered charges
related to preventive care covered at 80%, then normal plan provisions |
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Accident Benefit |
First $300 of covered charges due to an accident
covered at 100%, then normal plan provisions |
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Ambulance |
Deductible/70% |
Deductible/70% |
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Emergency
Room |
Deductible/70% |
Deductible/50% |
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Hospital
Inpatient |
Deductible/70% |
Deductible/50% |
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Inpatient Physical Rehabilitation |
Deductible/70% |
Deductible/50% |
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Facility |
Deductible/70% |
Deductible/50% |
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Physician |
70% |
Deductible/50% |
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Chiropractic
$100 allowance for X-rays
$400 allowance for routine exams
Deductible does not apply if services are performed by
member doctor |
Deductible/70% |
Deductible/50% |
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Outpatient Physical Therapy - $2,000 max/yr |
Deductible/70% |
Deductible/50% |
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Facility |
Deductible/70% |
Deductible/50% |
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Physician |
70% |
Deductible/50% |
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Mental
Illness: |
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Inpatient Facility - 21 day max |
Deductible/70% |
Deductible/50% |
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Inpatient Physician - 21 day max |
70% |
Deductible/50% |
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Outpatient Facility |
Deductible/70% |
Deductible/50% |
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Outpatient Physician |
70% |
Deductible/50% |
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Chemical
Dependency: |
$6,000 Max per
Benefit Period |
Inpatient Facility - $12,000
lifetime max |
Deductible/70% |
Deductible/50% |
Inpatient Physician - $12,000
lifetime max |
70% |
Deductible/50% |
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Outpatient Facility |
Deductible/70% |
Deductible/50% |
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Outpatient Physician |
70% |
Deductible/50% |
Contraceptives
Oral contraceptives paid in
accordance with the Prescription Drug benefit. |
$20
copay, then 60% |
$20
copay, then 60% |
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Retail
Prescription Drugs
(Par
Pharmacies)
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Generic: $10 Copay
Formulary Brand: $20 Copay
Non-Formulary Brand: $40
Copay |
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Retail RX Dosage
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34-Day Supply |
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Mail
Order Prescription Drugs
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Generic: $20 Copay
Formulary Brand: $40 Copay
Non-Formulary Brand: $80
Copay |
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Mail Order RX Dosage |
90-Day Supply |
*
Any amount you pay for services or supplies for the following
benefits do not apply to the maximum out-of-pocket amounts
listed: Rehabilitation therapy, durable medical
equipment and prosthetics, home health care, and balances owed
to nonparticipating providers.
**
Mammograms covered at 100% to a maximum of $70
***Nonparticipating Providers have
not contracted with BCBSMT. You will receive payment for
claims received from a nonparticipating provider. These
providers are under no obligation to send claims in for you.
Most importantly, nonparticipating providers are subject to a
differential. This means that BCBSMT reduces the
allowable fee by the following amounts before we calculate
your benefits:
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Professional (e.g., doctors,
physical therapists, nurse practitioners, radiologists)
Providers are subject to a 20% differential
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Facility (e.g., hospitals,
hospice, home health) Providers are subject to a 20%
differential.
Nonparticipating providers can
bill you the difference between the allowable fee and their
total charge, including the differential and any deductible
and copayments, potentially making your out-of-pocket expenses
significantly higher.
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