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Cicero Public School District #99
2013 Enrol ment Guide
for Nearly 1 in 3 Americans
Nearly one in every three Americans has a Blue Cross and Blue Shield product.
Experience
Preventive care is essential to maintaining a
healthier life, and no one understands this
better than Blue Cross and Blue Shield of Illinois
(BCBSIL). For more than 70 years, BCBSIL has
provided quality health care benefi ts and services
to its members and communities. BCBSIL provides
members with programs and support to create
customized wellness action plans, make smarter
health care choices and help manage their
health care.
Your Journey to Wellness
In This Guide
The following pages include a description of the
Wellness is defi ned as the state of being healthy
medical plan and other features and services
in body and mind, especially as the result of
available to you. In some cases, your employer
deliberate effort. The choices you make each
may be offering you more than one medical plan
day can affect your health now and in the future.
to choose from. Think carefully about how you
Deciding on the best approach for a healthier
and your family will use these benefi ts. Before you
lifestyle can be challenging, but it may be easier
make a decision, consider the services that are
than you think.
covered, provider network, potential out-of-pocket
BCBSIL offers access to convenient online tools
costs and other options.
and resources to help you plan and manage your health care. BCBSIL health care plans include
Blue Cross and Blue Shield
fl exible options with the right combination of benefi ts, choice of providers and access to a wide
of Illinois is a leader in
variety of educational resources. Whether you are trying to improve your health or reach the next
health care benefi ts.
level of wellness, BCBSIL is here to help.
Take time to explore what Blue Cross and Blue
Use the Health Plan Cost Estimator tool to help
Shield of Illinois has to offer. The coverage options,
you see how a medical plan fi ts your budget and
tools and resources can help you on your journey
your lifestyle. Go to
www.bcbsil.com/member and
to wellness.
click the Health Plan Decision Tools link.
If you have questions, your employer can provide additional information or direct you to other resources for assistance.
With the PPO plan,
The PPO Plan
you can choose any doctor
whenever you need care.
The PPO plan offers a wide range of benefi ts and the fl exibility to choose any doctor or hospital when you need care. The plan includes an annual deductible that you must satisfy before your benefi ts begin. Qualifi ed medical expenses are applied toward your deductible.
PPO Network
Access to the large network of contracting providers is one
will receive the highest level of benefi ts. If you use a
of the many reasons to select the PPO plan. The network
doctor outside the network, you'll still be covered, but
includes hospitals, physicians, therapists, behavioral health
your out-of-pocket costs may be signifi cantly higher.
professionals and alternative care practitioners.
To fi nd a contracting doctor or hospital, just go to
bcbsil.com
You and your covered dependents can receive care from any
and use the Provider Finder , or call BlueCard® Access at
licensed doctor, hospital or other provider. However, when
800-810-BLUE (800-810-2583) for help. Once you become a
you use a contracting network provider, you will pay less out
member, you can also call the toll-free customer service number
of pocket, you won't have to fi le any claims and you
on the back of your member ID card.
Medical CareYour benefi ts may include coverage for*:
• physician offi ce visits
• outpatient surgery and
• breast cancer screenings
• infertility treatment
• cervical cancer screenings
• maternity care
• inpatient hospital services
• behavioral health and
• muscle manipulation services
• outpatient hospital services
• hospital emergency medical and
• physical, speech and
accident treatment
occupational therapies
*Coverage levels vary by health plan, so refer to your plan documents for details.
The HMOs of Blue Cross and Blue Shield of Illinois (BCBSIL)provide the valuable benefits, member services and flexibility, along with the security of predictable copayments so there are no financial surprises. Unlike other plans, BCBSIL's HMOs do not require you to pay a deductible. Your employer may offer you the HMO Illinois plan, the BlueAdvantageSM HMO plan or a choice between the two.
When you join one of the HMOs of Blue Cross and Blue Shield of Illinois, you choose a contracting medical group within your network and then a family practitioner, internist or pediatrician from your chosen medical group to serve as your primary care physician (PCP). Your PCP provides or coordinates your health care, helps you make informed decisions and, when necessary, makes referrals to specialists who are usually within your medical group network. Each
HMO Networks
specialist referral is authorized for a specific number of visits
HMO Illinois offers access to one of the largest contracting
or timeframe (up to one year).
health care provider networks in Illinois. In fact, your regular doctor may already be part of the network. If your doctor is
In addition to their PCP, female members also have the
not in the network and you are undergoing a course of
option of choosing a Woman's Principal Health Care Provider
evaluation and/or medical treatment or are in the second or
(WPHCP) to provide or coordinate their health care services.
third trimester of pregnancy when you join the plan, you may
Your WPHC and PCP must be affiliated with or employed
request transition of care benefits. Benefits for transitional
by your Participating Medical Group. Physicians in the same
services may be authorized for up to 90 days. After this
medical group do have a referral arrangement. You do not
period, all care must be transferred to a new PCP/medical
need a PCP referral to see your WPHCP.
group in the HMO network. Contact Member Services for more information.
The BlueAdvantage HMO contracting provider network is a subset of the HMO Illinois network. Although smaller,
HMOs offer valuable
it offers a broad choice of contracting providers and is for
benefits with the security of
members who are looking for a more affordable health care plan. And BlueAdvantage HMO members have
access to the same contracting Illinois hospitals as HMO Illinois members for specialty care, with an approved referral from the member's contracting medical group.
The HMOs of Blue Cross and Blue Shield of Illinois have been awarded a Commendable Accreditation from
the National Committee for Quality Assurance (NCQA). This accreditation level is awarded to plans that
demonstrate levels of service and clinical quality that meet or exceed NCQA's rigorous requirements for
consumer protection and quality improvement. The NCQA results are publicly reported in five categories:
• Access and Service • Qualified Providers • Staying Healthy • Getting Better • Living with Illness
If you have a question, visit bcbsil.com
or call Member Services at 800-892-2803.
Medical Care
The range of benefits includes coverage for:
Another HMO benefit is coverage for preventive health
• Physician office visits
services for children and adults, such as routine physicals,
• Outpatient surgery and diagnostic tests
screenings, tests and immunizations, including childhood
• Breast cancer screening
immunizations. Also, BCBSIL sends reminders to members to
• Cervical cancer screening
schedule flu shots, mammograms and Pap tests, and to have
• Prostate cancer screening
early childhood immunizations completed.
• Colon cancer screening
Vision Care
• Inpatient hospital services
You and your covered dependents are eligible to receive
• Maternity care
an eye examination and contact lens evaluation, fitting and
• Outpatient hospital services
follow-up once every 12 months, for the cost of your PCP or
• Mental health and substance abuse – inpatient and
wellness copayment. Your vision care benefits are available
outpatient treatment (Note: Physicians Care Network (PCN),
through Davis VisionSM, a leading national provider of routine
Inc. members' mental health care is directly coordinated
vision care programs.
ork mental health pro arded an Excellent
Accreditation from the National Committee for Quality
• Rehabilitative therapy (such as physical, speech and
Assurance (NCQA). This accreditation level is awarded to plans that demonstr
ate levels of service
Urgent CareSM
occupational therapy)
and clinical quality that meet or exceed NCQA's rigorous requirements for consumer protection and
This program covers HMO members traveling outside of
• Inpatient and outpatient treatments
quality improvement. The NCQA results are publicly reported in fiv
ho need medical attention for a condition that is
not an emergency.
To find a medical group and PCP in either network, go to
• Access and Service • Qualified Providers • Staying H
acting pro etter • Living with
bcbsil.com and use the Provider Finder® or refer to a printed
vider in the area in which you are
directory. You can request a directory by calling Member
traveling, call the BlueCard program toll-free at 800-810-BLUE
Services at the toll-free number on the back of your BCBSIL
(800-810-2583) or search the Blue Cross and Blue Shield
ID card. Each covered family member can choose a different
Association's Web site at
bcbs.com. You can then call the
medical group or PCP from the network. It's also easy to
provider directly to make an appointment. You pay the
change your PCP or medical group for any reason. To select
applicable copayment at the time of service and don't need to
a different PCP within your existing medical group, just call
submit claim forms.
the medical group. To change your medical group, call Member Services or use the Blue Access for Members online service at
bcbsil.com. See Your Health Care Benefit Program booklet or call Member Services for more information.
If you have a question, visit bcbsil.com or call Member Services at 800-892-2803.
This program covers members who are living out of the
Federal and State of Illinois legislation require that group
participating service area for at least 90 consecutive days.
health plans and health insurers provide coverage for
You can become a Guest Member with full benefits through
reconstructive surgery following a mastectomy. These laws
a Blue Cross and Blue Shield HMO in another state. Guest
state that health plans that cover mastectomies must also
Membership is a particularly valuable benefit for covered
provide coverage in a manner determined in consultation
students who are living out of state while attending school or
with the attending physician and patient for reconstruction
for members on extended travel out of state.
of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a
To find out if Guest Membership is available at your
symmetrical appearance, and prostheses and treatment for
destination or to sign up with a host Blue Cross and Blue
physical complications for all stages of mastectomy care,
Shield HMO in another state, you must call Member Services
before leaving home or before receiving any out-of-state services. If not, there will be no coverage for services received
The HMOs of Blue Cross and Blue Shield of Illinois
out of state. After applying, if you plan to continue with Guest
cover these procedures and annual mammograms when
Membership, you must renew it after a defined period of time.
ordered by a member's primary care physician or Woman's Principal Health Care Provider, subject to the
terms of the member's applicable health care benefit
The HMOs of Blue Cross and Blue Shield of Illinois give you
coverage. Visit us at
bcbsil.com or call Member
access to health care benefits when traveling or temporarily
Services for more information.
living out of state.
The HMOs of Blue Cross and Blue Shield of Illinois support
If you, as a prudent layperson with an average knowledge
the belief that the best people to determine what medical
of health and medicine, need to go to the emergency room
care you need are you and your doctor. BCBSIL does not
of any hospital, your care will be covered. When a medical
get involved in deciding your course of treatment. This sets
emergency occurs, first try to call your PCP. Someone from
it apart from most other HMOs. Your doctor is encouraged
your medical group is available 24 hours a day, seven days a
to listen to your concerns and discuss all treatment options
week. Your PCP or another doctor in your medical group may
with you to help you make informed decisions. Your network
be able to treat you in the office. If you are unable to call your
medical group may review certain referrals or procedures for
PCP, go directly to the nearest hospital emergency room and
appropriateness of care. Your HMO doesn't get involved unless
notify your PCP as soon as possible.
you request an appeal from BCBSIL because you disagree with decisions made by your PCP or medical group
If you are admitted, someone must contact your PCP immediately upon admission. Your emergency room
Substance Abuse Treatment
copayment will be waived, but you will have to pay your
Substance abuse treatment is provided at contracting
inpatient hospital copayment, if applicable. Emergency
facilities and a PCP referral is not needed. Call the number
care benefits are limited to the initial emergency treatment.
on the back of your ID card to locate a participating
To receive additional benefits, your PCP must provide or
substance abuse provider.
coordinate follow-up care.
This document is for comparison purposes only and is a brief summary of benefits. For full benefit information, please refer to your contract or certificate (Health Care Benefit Program booklet).
If you have a question, visit bcbsil.com or call Member Services at 800-892-2803.
Other Benefits for non-HMO plans
Your health care benefit plan travels with you wherever you go – across the country or around the world.
Preventive Care
Your coverage may include preventive care benefits for children and adults, including physical exams, diagnostic tests and
immunizations. Check your group plan for the specific coverage.
Emergency Care
If you, as a prudent layperson (with an average knowledge of health and medicine) need to go to the emergency room of any
hospital, your care will be covered subject to your plan's deductible and any applicable copayments or coinsurance. In an
emergency, you should seek care from an emergency room or other similar facility. Call 911 or other community emergency
resources to obtain assistance in life-threatening situations. Your group plan may require that you, a family member or friend
contact BCBSIL if you are admitted to the hospital.
You have nationwide access to contracting providers in
With the BlueCard program, there are two ways to locate
networks linked through the BlueCard® program when you
contracting doctors and hospitals:
or your covered dependents live, work or travel anywhere
• Visit the Web site at
www.bcbsil.com to find provider
in the country. The national network includes more than 85
names and locations using the Provider Finder. Maps and
percent of all physicians and hospitals in the country. Be sure
driving directions are also available.
to use a BlueCard network provider to receive the highest level
• Call the toll-free customer service number on the back of
your ID card.
physical complications for all stages of mastectomy, including lymphedemas.
Your coverage may also include benefits for baseline and annual mammograms. Check your group plan documents for details.
Illinois Dependent Eligibility Mandate
Under new, Federal law, your dependents are eligible
for health and/or dental coverage up to the dependent
limiting age and may not be denied coverage due to marital,
student or employment status before age 26. Check with
Reconstructive Surgery
your employer for additional details regarding eligibility requirements. In addition, eligible military personnel may not
be denied coverage before age 30 under Illinois law. If you elect
Federal and State of Illinois legislation require group
Blue
Choice Select coverage, your dependents must live within
health plans and health insurers to provide coverage for
the defined service area.
reconstructive surgery following a mastectomy. Specifically, these laws state that health plans that cover mastectomies must
This Illinois law applies to all individual plans and insured
also provide coverage in a manner determined in consultation
group medical and/or dental plans, as well as self-insured
with the attending physician and patient for reconstruction
municipalities, counties and schools. The law does not apply
of the breast on which the mastectomy has been performed,
to self-funded national account groups or local non-municipal
surgery and reconstruction of the other breast to produce a
self-funded groups. If you have questions about this law,
symmetrical appearance, and prostheses and treatment of
contact your benefits administrator.
When you travel outside the United States and need medical assistance services, call 800-810-BLUE (800-810-2583) or call collect to 804-673-1177 for information. Blue Cross and Blue Shield has contracts with doctors and hospitals in more than 200 countries. An assistance coordinator, in conjunction with a medical professional, can arrange your doctor's appointment or hospitalization, if necessary.
Providers that participate in the BlueCard Worldwide® program, in most cases, will not require you to pay up front for inpatient care. You are responsible for the out-of-pocket expenses such as a deductible, copayment, coinsurance and non-covered services. The doctor or hospital should submit your claim.
You also have coverage at non-contracting hospitals, but you will have to pay the doctor or hospital for care at the time of service, then submit an international claim form with original bills. Call the toll-free customer service number on your ID card for the address to send the claim. You can get a claim form from your employer, customer service or online at
www.bcbsil.com.
Prescription Drugs
Save money by choosing generic drugs instead of brand drugs.
Prescription Drug Benefi ts
medication. You can print registration and order forms, request
Non-HMO Plans
prescription refi lls and see the status of orders you've placed,
Your benefi ts include prescription drug coverage through
learn more about generic drugs and more when you visit the
Blue Cross and Blue Shield of Illinois. You have access to a
Web site at
www.bcbsil.com and log in to Blue Access®
national network of contracting pharmacies, which includes
for Members.
most national chain as well as independent pharmacies across the country. When you visit a contracting pharmacy and show
Prescription Drug Card Program
your BCBSIL card, the claim is processed immediately at the
time of purchase based on your medical plan deductible,
Your HMO benefi ts include prescription drug coverage. The
coinsurance and out-of-pocket limitations. You are only
outpatient prescription drug program is based on a tiered
responsible for your share of the discounted price of
formulary structure. The formulary is a list of all generic drugs
and a large selection of brand drugs. It is regularly reviewed and revised and is subject to change throughout the year.
Mail Service
While coverage may vary depending on your health care
You can receive up to a 90-day supply of maintenance
benefi t plan, you usually pay less for covered formulary drugs
medication delivered directly to you. Mail service claims
than for non-formulary drugs. The BCBSIL formulary structure
are processed based on your medical plan deductible,
provides coverage for nearly all drugs, even those that are not
coinsurance and out-of-pocket limitations, and you are only
on the formulary. Check the formulary at
www.bcbsil.com.
responsible for your share of the discounted price of the
Log in to Blue Access for MembersSM (BAM)
Your Online Resource
Would you like to know when your medical claims are paid and the payment amounts? Do you need to confirm who in your family is included under your coverage? BAM, the secure member portal from Blue Cross and Blue Shield of Illinois (BCBSIL), can
help. Get immediate online access to health and wellness information, and:
• Check the status of a claim and your
• Confirm the family members who are covered
• View and print an Explanation of Benefits
(EOB) statement for a claim
• Select an option to stop receiving EOBs
• Set your preferences to receive notifications
for claims status and wellness updates
Use BAM while you're on the go.
through emails or text alerts.
Register or log in by going to bcbsil.com
• Locate a doctor or hospital in the network
from your mobile device Web browser for
• Request a new or replacement member ID
secure and convenient access.
card or print a temporary member ID card
• Join My Blue Community®, a social network
It's easy to get started
1. Go to bcbsil.com.
2. Click the Already a Member? tab. Then click
the Register Now button in the BAM section.
3. Use the information on your BCBSIL ID card
to complete the registration process.
Find what you need at Blue Access for MembersSM (BAM)
My Coverage
My Health
Doctors & Hospitals
Forms & Documents
Welcome Jose Martinez
Last login 07/17/2012
Quick Links
MY COVERAGE
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4 new messages.
Billed AmountPlan Type: PPO+
Group Number: P12345
My Blue Community
ID Number: 0001233456789
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My Blue Community
Manage Preferences
In Network Benefits
Find a Doctor, Hospital or
Protecting Your Online
System Maint Test
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PREAUTHORIZATION PENALTY
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DEDUCTIBLE PER FAMILY
DEDUCTIBLE PER INDIVIDUAL
OUT OF POCKET PER FAMILY
View medical benefits >>
Prescription Drug Copay
Blue Access for Members
Is New and Improved.
We've made Blue Access
for Members easier to use.
Formulary Brand - Mail
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My Spending Accounts Balance
1.
My Coverage: Review
5.
Forms & Documents:
8.
Settings: Set up notifications
Form Finder
benefit details for you and the
Use the form finder to get
and alerts to receive updates
family members cov
Health Care Account(s)
medical, dental, pharmacy and
via text messaging and
for browse our list
other forms quickly and easily.
email, review your member
Your Flexible Spending Account information is unavailable at this time due to a system error.
Please check you account again later or contact us.
2.
Claims Center: View and
6.
Message Center: Learn about
information, and change your
organize details such as
updates to your benefit plan,
secure password at anytime.
MY CLAIM ACTIVITY
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payments, dates of service,
and receive notification of
9.
Help: Look up definitions of
provider names, claims status
pending and finalized claims
health insurance terms, get
Service Date
via secure messaging.
answers to frequently asked
questions and find Health Care
STAMPER M.D.
3.
My Health: Make more
7.
Quick Links: Go directly
informed health care
to some of the most popular
School articles and videos.
BURNS, D.D.S.
decisions by reading about
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10.
Contact Us: Submit a
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such as medical coverage,
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and researching specific
replacement ID cards, manage
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respond by phone or through
4.
Doctors & Hospitals: Use
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Provider Finder® to locate a
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network doctor, hospital or other health care provider, and get driving directions.
Frequently Asked Questions
Q: What questions should I ask when selecting a doctor?
A: In addition to preliminary questions you'd ask a new doctor—such as "Are you accepting new
patients?"—the following questions will help you evaluate whether a doctor is right for you:
• What is the doctor's experience in treating patients with the same health problems I have?
• Where is the doctor's offi ce? Is there ample parking or is it close to public transportation?
• What are the regular offi ce hours? Does the offi ce have drop-in hours for urgent problems?
• How long should I expect to wait to see the doctor when I'm in the waiting room?
• Are routine lab tests and X-rays performed in the offi ce, or will I have to go elsewhere?
• Which hospitals does the doctor use?
• If this is a group practice, will I always see my chosen doctor?
• How long does it usually take to get an appointment?
• How do I get in touch with the doctor after offi ce hours?
• Can I get advice about routine medical problems over the phone or by e-mail?
• Does the offi ce send reminders for routine preventive tests, like cholesterol checks?
Q: Whom do I call with questions about my benefi ts?
A: Call customer service at the toll-free number on the back of your member ID card.
Q: How do I fi nd a contracting network doctor or hospital?
A: Go to www.bcbsil.com and use the Provider Finder® or call customer service at the toll-free number on the back of your
member ID card.
Q: What should I bring to my fi rst appointment?
A: Your fi rst appointment is an opportunity to share information about your health with your new doctor, so bring as much
medical information as possible, including:
Medical records and insurance card – If you are undergoing treatment when you change doctors, your medical records are especially important to your new doctor. Your BCBSIL member ID card provides information about copayments, billing and customer service phone numbers.
Medications – Give your new doctor information on prescription and over-the-counter medications, including any herbal medications you take. Be sure to include the name of the medication, the dosage, how often you take it and why.
Special needs – Make a list of medical equipment and devices you use, including wheelchairs, oxygen, glucose monitors and glucose strips. Be prepared to explain how you use them, not only to make sure you have the equipment you need, but also to avoid any disruption in your care.
Q: Are my medical records kept confi dential?
A: Yes. Blue Cross and Blue Shield of Illinois is committed to keeping specifi c member information confi dential. Anyone
who may need to review your records is required to keep your information confi dential. BCBSIL may need to review your medical record or claims data (for example, as part of an appeal that you request). If so, precautions are taken to keep your information confi dential. In many cases, your identity will not be associated with this information.
Be Smart. Be Well.®
You can increase your odds of living better and
living longer by making smart health and safety choices.
Be Smart. Be Well. is a unique Web site dedicated to helping you be safe and healthy. Be Smart. Be Well. features engaging video documentaries of the personal lessons learned by real people. The goal of Be Smart. Be Well. is simple: to give you the information and resources you need to make an immediate and positive impact on your everyday life.
Highlights of the site include:
Be Smart. Be Well. is sponsored by Health Care Service
• Simple steps you can take to live healthier
Corporation, the largest customer-owned health insurer in the United States, with more than 12 million members in its Blue
• Links to useful resources
Cross and Blue Shield Plans in Illinois, New Mexico, Oklahoma
• Information provided by medical professionals
• Timely newsfeeds from national media
Be sure to join the daily discussion on Twitter at twitter.com/bsbw and visit us on You Tube at
Numerous health and safety topics including mental health,
childhood obesity, drug safety and caregiving are presented on the site. New topics are continually added.
Be Smart. Be Well. Know the facts. Visit www.besmartbewell.com today.
Drug Safety
Divisions of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licenseeof the Blue Cross and Blue Shield Association.
This information is not intended to be a substitute for professional medical advice. If you are under the care of a doctor and receive advice contrary to this information, follow the doctor's advice. See your doctor if you are experiencing any symptoms or health problems.
Understanding Your EOBA Guide to Reading Your Explanation of Benefi ts Statement
An Explanation of Benefi ts (EOB) Statement is a notifi cation form provided to members when a health care benefi ts claim is processed by Blue Cross and Blue Shield of Illinois (BCBSIL). The EOB displays the expenses submitted by the provider and shows how the claim was processed.
The EOB has four major sections:
• Claim Information includes the member
and patient name, the member's group and ID numbers, and the claim number.
• Summary highlights the fi nancial information
– the amount billed, total benefi ts approved and the amount you may owe the provider.
• Service Information identifi es the health
The EOB may include
care facility or physician, dates of service and
additional information.
• Information About Amounts Not Covered
will show what benefi t limitations or exclusions
• Coverage Information shows what was paid
to whom, what discounts and deductions apply, and what part of the total expense was not
• Information About Out-Of-Pocket
Expenses will show an amount when a claim
applies toward your deductible or counts
toward your out-of-pocket expenses.
• Information About Appeals explains your
rights regarding review of claim denials.
• Fraud Hotline is a toll-free number you can
call if you think you are being charged for services you did not receive or if you suspect any fraudulent activity.
Your EOBs are Always Available Online!
Sign up for Blue Access® for Members (BAM) at www.bcbsil.com for quick, convenient and confi dential
access to your claim information and history. To support our commitment to eco-friendly business
practices, you can choose to opt out of receiving EOBs by mail. This saves resources and offers you
additional confi dentiality. Just go to BAM, click on User Profi le and change your User Preferences.
Account name (member's company or organization)
Date claim was fi nalized
Toll-free number to call for additional information
Member's name and mailing address
Employer or group identifi cation number*
Member number that appears on the ID card*
Person who received the services*
Summary box, including the total amount billed by the provider for the services, the benefi ts approved and paid by BCBSIL, and the remainder you may owe.
(See also 14, 20 and 21).
Provider name (top line) and description of service (below)
Beginning and end service dates
Amount billed by the provider for each service
Portion of the billed amount not covered by the plan(a footnote explains the reason)
Amount covered by the plan*
Total charges included on this claim
Plan reductions subtracted from billed amount, such as PPO allowances
Deductible and copayment or coinsurance amounts
Payment approved before benefi ts are coordinated with other insurers, such as Medicare
Amount the member may be responsible for paying
Total benefi t approved for provider
* Please provide this information when contacting us about a claim.
Not all EOBs are the same. The format and content of your EOB depends on your benefi t plan and the services provided. Deductible and copayment amounts vary.
Quick and Easy Ways to Find a Doctor
Use Provider Finder®, a reliable and convenient tool, to locate doctors, dentists and pharmacies in your network. Filter search results by provider type, specialty, network type, ZIP code, language and gender. Get directions from Google Maps™, too. It's now faster and simpler to do than ever before!
Online
Go to bcbsil.com and click on Find a Doctor. The
improved search experience on Provider Finder
means you need fewer clicks and required fields to
get your results!
On your mobile device - New!
Go to bcbsil.com from your mobile phone's Web
browser and click on Find a Doctor or Hospital.
Or download the Provider Finder App for your
iPhone® or Android® phone. If you use your GPS
location or input a ZIP code, the App can pinpoint
the closest provider locations for you.
On the phone
If you prefer, call a Blue Cross and Blue Shield
of Illinois (BCBSIL), a division of Health Care
Service Corporation, Customer Service Advocate
at the toll-free telephone number on the back of
your BCBSIL member ID card for help in locating
a provider.
Blue Access MobileSM
Blue Access Mobile brings convenient, secure access to your mobile phone.
From your mobile phone Web browser, you can:
• Register or log in to your secure member site – Blue Access for MembersSM – to
view coverage details, access identification (ID) cards, check claims status, manage your user profile and view health and wellness information
• Download the Provider Finder® app to find an in-network doctor or hospital.
• Sign up for text or email notifications, tips and reminders
• Access Health Care 101 to view general health insurance information and terminology
• Shop for insurance and get a quote before applying
It is easy to experience Blue Access Mobile. Simply go to bcbsil.com from your
mobile phone Web browser.
There is no registration required to access the mobile site. However, BCBSIL members
must enter their user name and password to log in to Blue Access for Members.
Q&A Prescription Drug Formulary
What is a formulary?
How do I know if a drug is on the
The Blue Cross and Blue Shield of Il inois formulary,
formulary and what my cost will be?
which your prescription drug benefit plan is based
On the fol owing pages are some commonly
on, is a regularly updated list of preferred drugs
prescribed generic and formulary brand medications.
selected based on the recommendations of a
If a drug you are looking for is not on the list, search
committee comprised of individuals from throughout
the formulary at bcbsil.com or call the Pharmacy
the country who hold a medical or pharmacy
Program number on the back of your ID card.
degree. U.S. Food and Drug Administration (FDA)-approved drugs are chosen based on efficacy, safety,
Your particular prescription drug benefit plan and
uniqueness and cost-effectiveness. The formulary
whether or not the drug is on the formulary wil
includes all generic drugs and a select group of
determine the amount you pay. To find out what
brand drugs.
you will pay, visit our website at bcbsil.com or call the Pharmacy Program number on the back of your
What are the advantages of using
What are drug dispensing limits?
Your copayment/coinsurance amount for covered
Based on FDA-approved dosage regimens and
formulary drugs is usually lower than for non-
manufacturer's product packaging, certain
formulary drugs. You have benefits for most
medications have dispensing limits. This means that
covered medications that are not on the formulary,
only a specific quantity of medication is covered per
but you may pay more out-of-pocket. The
prescription or in a given time period. For example,
formulary is a reference for your doctor when
coverage for the osteoporosis drug Actonel®
prescribing medications. However, it is solely
(risedronate) is limited to 30 tablets per 30 days
up to you and your physician to determine the
because the FDA-approved labeling states that
medication that is best for you.
the recommended dose is one 5 mg oral tablet taken daily.
What are the advantages of using
What if I have questions?
Generics are recognized as safe and effective
Call the Pharmacy Program number on the back of
medications. Generics cost less because
your ID card, 24 hours a day, 7 days a week, or visit
manufacturers do not have to recover an investment
bcbsil.com. Drug safety information is also available
in research and development. Therefore, you usual y
at besmartbewel .com/drugsafety.
pay less for a generic drug than for a brand medication. A generic can usual y be substituted for a brand drug if it contains the same active ingredients, the same strength and dosage form and produces the same results. Only your doctor can make prescribing decisions for you. Talk to your doctor or pharmacist to find out if a generic drug is available and right for you.
April 2013
Commonly Prescribed Formulary Medications
This list is a sample of commonly prescribed generic and formulary brand drugs. Refer to the Blue Cross and Blue Shield of Il inois
Prescription Drug Formulary at bcbsil.com for a more comprehensive and up-to-date list. The online formulary is updated after
new generic drugs become available and also on a regular basis. The formulary may contain medications not covered under your
prescription drug benefit plan. In addition, prescription versions of over-the-counter (OTC) medications may not be covered based on
your prescription drug benefit plan. If you have questions about your prescription drug benefit, call the Pharmacy Program number on
the back of your ID card.
CARDIOVASCULAR
Proton Pump Inhibitors
captopril/captopril HCT
enalapril/enalapril HCT
bupropion ext-release 24 hr
amoxicil in/clavulanate
quinapril/quinapril HCT
azithromycin tabs/susp
Angiotensin II Receptor Blockers
losartan/losartan HCT
BENICAR/BENICAR HCT
Dipeptidyl Peptidase 4 Inhibitors
bisprolol/bisprolol HCT
JANUMET/JANUMET XR
metoprolol/metoprolol ER
Calcium Channel Blockers
Cholesterol Lowering Drugs
LOW MOLECULAR WEIGHT HEPARIN
Monitoring Kits/Strips & Syringes
ACCU-CHEK STRIPS & KITS
ACCU-CHEK LANCETS
BAYER BREEZE STRIPS
BAYER CONTOUR STRIPS
BAYER MICROLET LANCETS
BD NEEDLES/SYRINGES
CHEMSTRIP BG STRIPS & KITS
H2 Receptor Antagonists
ofloxacin ophth soln
polymyxin B/trimethoprim
April 2013
Commonly Prescribed Formulary Medications
FORADIL AEROLIZER
brimonidine 0.15%, 0.2%
EE/norethindrone (Necon 7/7/7*,
timolol maleate soln
Cough and Cold
EE/norgestimate (Tri-Sprintec*, Trinessa*)
All generical y available cough/cold
medications that require a prescription are
norethindrone (Errin*, Jolivette*)
on the formulary.
Other Eye Products
levonorgestrel 0.75 mg
ketorolac soln 0.4%, 0.5%
COMBIVENT RESPIMAT
SPIRIVA HANDIHALER
SLEEP AIDS
progesterone micronized
levothyroxine – includes Levoxyl*
Benign Prostatic Hypertrophy
tolterodineDETROL LA
Allergy Drugs
Al generical y available antihistamine/
decongestant combinations that require a
prescription are on the formulary.
EE/desogestrel (Apri*)
EE/drospirenone (Gianvi*, Ocella*, Zarah*)
EE/levonorgestrel (Aviane*, Levora*)
EE/norethindrone (Necon*, Necon 1/35*, Nortrel*, Nortrel 1/35*)
Asthma Drugs
EE/norgestimate (Mononessa*, Sprintec*)
zafirlukastADVAIR DISKUS/ADVAIR HFA
EE/desogestrel (Kariva*)
EE/norethindrone (Necon 10/11*)
FLOVENT DISKUS/FLOVENT HFA
Formulary brand drugs are noted with names in UPPERCASE. Certain generic drug products are listed by their proprietary name, and are indicated with an asterisk (*). EE = ethinyl estradiol Drug trademarks and servicemarks are the property of their respective third-party owners.
Save when you use Generic Drugs
Talk to Your Doctor and Pharmacist
Your doctor uses clinical knowledge and judgment to prescribe drugs that meet your needs. The next time your doctor writes
you a prescription, consider asking if a generic is available and right for you. When purchasing a prescription, you can tell the
pharmacist that you would like the generic equivalent, if available, unless your doctor indicates otherwise.
Frequently Asked Questions
Are generic drugs as safe as brand drugs? Generic drugs are reviewed and approved by the U.S. Food and Drug
Administration (FDA), just as brand drugs are. According to the FDA, compared to a brand drug, a generic equivalent:
• is chemically the same
• works the same in the body
• meets the same standards set by the FDA
• is as safe and effective.
Why do generic drugs cost less? Generic drugs tend to cost less than the equivalent brand drug because the companies thatmake them do not have to recover the costs of research and development. On average, generic drugs cost 30 to 80 percent lessthan their brand counterparts.* Please keep in mind, however, that your out-of-pocket expense will be determined by yourparticular benefit plan.
Is there a generic drug available for my condition? Most likely. Sixty-three percent of all prescriptions dispensed in the UnitedStates are filled with generic drugs.**
A Good Choice
Your doctor will determine the appropriate medication for you. Consider asking if a generic equivalent is available for your
prescription. Remember, you get a drug with the same active ingredients at the same dosage as the brand drug – usually at a
lower cost.
Below are some of the most commonly prescribed brand drugs and their generic equivalents. Ask your physician to approvethe generic equivalent whenever possible by writing the generic name on the prescription.
Common Brand Drugs and Their Generic Equivalents
Brand Name Generic Name
Brand Name Generic Name
Brand Name Generic Name
Mevacor lovastatin
Micronase glyburide
Norvasc amlodipine Tylenol
Pepcid famotidine Ultram tramadol
Cardizem diltiazem
Vasotec enalapril
Ventolin albuterol
Prinivil lisinopril
Wellbutrin bupropion
Diabeta glyburide
Procardia nifedipine
Proventil albuterol
Prozac fluoxetine Yasmin
drospirenone/ethinyl
Retin-A tretinoin
estradiol; branded
Glucophage metformin
generic called Ocella
Glucotrol glipizide
Zantac ranitidine
Hytrin terazosin
Zestril lisinopril
Timoptic timolol
Lasix furosemide
Lopid gemfibrozil
Zovirax acyclovir
As always, you should discuss with your physician questions or concerns about any drugs you are taking. Your doctor candetermine whether a generic drug is appropriate for you.
*The National Association of Chain Drug Stores
**IMS Health
Specialty MedicationsBlue Cross and Blue Shield of Illinois (BCBSIL) has arranged for Prime Specialty Pharmacy* to support members who require specialty medication and help them manage their therapy.
Specialty medications are generally prescribed to treat chronic, complex medical conditions, such as multiple
Sample Medications**
sclerosis, hepatitis C and rheumatoid arthritis. These medications are typically received by injection or infusion, but may be topical or taken by mouth. Specialty drugs often
require careful adherence to a treatment plan and have special handling or storage requirements and may not be
Gleevec, Nexavar, Sprycel,
stocked by retail pharmacies.
Genotropin, Humatrope,
Some specialty medications must be given by a health care
Norditropin, Omnitrope,
professional, while others are self-administered. Medications
that require professional services for administration are usually covered under your medical benefit. Your doctor
Hepatitis C
Copegus, Infergen,
will order these medications. Coverage for self-administered
Intron-A, Pegasys,
specialty medications is usually provided through your
pharmacy benefit. Your doctor should write or call in a prescription for self-administered specialty medications for
Avonex, Betaseron,
receipt from a specialty pharmacy provider.
Rheumatoid
Enbrel, Humira, Kineret
Examples of Self-administered
Specialty Medications
The chart to the right shows some conditions
Other conditions that specialty medications may be used
self-administered specialty medications may be used
to treat include cystic fibrosis, hemophilia, infertility, lung
to treat, along with sample medications. This list is not
disorders and pulmonary arterial hypertension.
all-inclusive and may change from time to time. Visit bcbsil.com to see the current list of specialty medications.
Support in Managing Your Condition:
Call Prime Specialty Pharmacy at 877.627.MEDS (6337)
Prime Specialty Pharmacy
to order. Have your member ID card and the following
information ready:
Through Prime Specialty Pharmacy, you can have your
• Name, address, phone number
covered self-administered specialty medication delivered
• Name of medication
directly to you, or to your doctor's office. When you get your specialty medication through Prime Specialty Pharmacy, you
• For existing prescriptions, your current pharmacy's name
receive support in managing your therapy – at no additional
and phone number, and the prescription number
charge – including:
• Doctor's name, phone and fax numbers
• Assistance with coverage between you, your doctor
Receiving Specialty Medications
• Convenient delivery of medication to you or your
Since many specialty medications have unique shipping or
handling requirements, shipments will be arranged with you
• Information about your particular condition and about
through Prime Specialty Pharmacy. Medications are shipped
managing potential medication side effects
in plain, secure, tamper-resistant packaging.
• Syringes, sharps containers and other supplies with
every shipment for self-injectable medications
Prior to your scheduled refill date, you may be contacted to:
• 24/7/365 customer service phone access
• Confirm your medication, dosage and the
delivery location
Ordering Through Prime
• Review any prescription changes your doctor may
• Discuss any side effects you may be experiencing
To begin using Prime Specialty Pharmacy, call 877.627.MEDS (6337). If you currently use a self-administered specialty
If you need assistance, you can reach Prime Specialty
medication, you can have your existing prescription transferred
Pharmacy at 877.627.MEDS (6337).
to Prime Specialty Pharmacy. If you have a new prescription, Prime Specialty Pharmacy can provide you more information about submitting the prescription or having your doctor do so. Your doctor may also order office-administered specialty medication through Prime Specialty Pharmacy.
Please note that some members may not have coverage for self-administered specialty medications. In addition, the list of specialty medications may include drugs that are not covered under your benefit because of specific exclusions. Check your benefit booklet for details, or call the number on the back of your member ID card with questions.
*Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC, a pharmacy benefit management company. Blue Cross and Blue Shield of Illinois contracts with Prime Therapeutics to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. Blue Cross and Blue Shield of Illinois, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.
**Third-party brand names are the property of their respective owners.
BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
24/7 Nurseline* – Around-the-Clock, Toll-Free Support
The 24/7 Nurseline can help you figure out if you should call your doctor, go to the ER or treat the problem yourself.
Health concerns don't always follow a 9-to-5 schedule. Fortunately, registered nurses are on call at (800) 299-0274 to answer your health questions, wherever you may be, 24 hours a day, seven days a week.
The 24/7 Nurseline's registered nurses can understand your health concerns and give general health tips. Get trusted guidance on possible emergency care, urgent care, family care and more.
When should you call?The toll-free Nurseline can help you or a covered family member get answers to health problem questions, such as:
• Asthma, back pain or chronic health issues
• Dizziness or severe headaches
• High fever
• A baby's nonstop crying
Plus, when you call, you can access an audio library of more than 1,000 health topics—from
• Cuts or burns
allergies to women's health—with more than 600
• Sore throat
topics available in Spanish.
Note: For medical emergencies, call 911 or your local emergency services first. This program is not a substitute for a doctor's care. Talk to your doctor about any health questions or concerns.
*The 24/7 Nurseline is not available to HMO members.
Get the information you need, just when you need it.
a New Way to Experience Wellness
Well onTarget offers personalized tools and resources to help all members—no matter where you may be on the path to health and wellness.
Liveon Member Wellness Portal
The heart of Well onTarget is the Liveon portal. It uses the latest technology to offer
you an enhanced online experience. This engaging portal links you to a suite of
innovative programs and tools.
• onmytime Self-directed Courses
Online courses let you work at your own pace to reach your health goals. Learn more on nutrition, fitness, weight management, tobacco cessation and stress. Track your progress as you make your way through each lesson. Reach your milestones and earn Life Points.
• Health and Wellness Content
Health library teaches and empowers through evidence-based, user-friendly articles.
• Tools and Trackers
Interactive tools help keep you on course while making wellness fun. Use food and workout diaries, health calculators and medical and lifestyle trackers.
Wel ness is more than
onmywayTM* Health Assessment (HA)
healthy eating and
The HA features adaptable questions to learn more about you. After you take the HA, you will get a personal wellness report. The confidential record offers tips for
working out. It involves
living your healthiest life. Your answers will be used to tailor the Liveon portal with
making healthy choices
the programs that can help you reach your goals.
that enrich your mind,
Life Points Program
Life Points will help motivate you to maintain a healthy lifestyle. Earn points
body and spirit.
by taking part in wellness activities. Points can be redeemed in the new online
Well onTarget is designed
shopping mall. Real-time granting of points lets you instantly use your points. To earn a larger reward, you can add to your point total at checkout.
to give you the support you need to make these
Fitness can be easy, fun and affordable. The Fitness Program is a flexible
choices. All while
membership program that gives you unlimited access to a nationwide network of
rewarding you for
fitness centers. With more than 8,000 participating gyms on hand, you can work out at any place or at any time. Choose a gym close to home and one near your
office. Other program perks are:• No long-term contract required. Membership is month to month. Monthly fees
Service mark of Health Care Service Corporation,
are $25 per month per member, with a one-time enrollment fee of $25.
a Mutual Legal Reserve Company
• Automatic withdrawal of monthly fee.
Onlife Health is an independent company and provides wellness services for Blue Cross and Blue Shield of Illinois, Blue
• Online tools for locating gyms and tracking visits.
Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma and Blue Cross and Blue Shield of Texas.
• Earn bonus Life Points for joining the Fitness Program. Rack up more points with
* onmyway is registered mark of Onlife Health.
weekly visits.
Healthways, Inc. is an independent contractor which administers the Prime Network of fitness centers. The Prime
Sign up today! Call toll-free at 888-762-BLUE (2583), Monday through Friday,
Network is made up of independently-owned and managed
8 a.m. – 9 p.m. in any continental U.S. time zone.
fitness centers.
All trademarks and service marks are property of their respective owners.
A Discount Program for Members
Blue365 is just one more advantage of being a Blue Cross and Blue Shield of Illinois (BCBSIL) member. With this
program, you can save money on health care products and services that are most often not covered by your benefi t
plan. There are no claims to fi le and no referrals or pre-authorizations.
Blue365 has a range of new features and greater discounts from top national and local retailers on fi tness gear, gym memberships,
family activities, healthy eating options and much more. Once you register on the Blue365 website at blue365deals.com/BCBSIL,
you will receive weekly "Featured Deals," which will offer additional discounts from leading health companies and online retailers
that are available for a short period of time.
Davis VisionSM' TruVision
Save on eyeglasses, as well as contact lenses, laser vision
Jenny Craig can help you reach your weight-loss goals. You
correction services, examinations and accessories. For a list
will get one-on-one support given by a trained weight-loss
of Davis Vision providers near you, go to bcbsil.com, click
expert. Your consultant will give you a tailored program
Find a Doctor then select Find a Vision Provider. The Davis
based on the essential components of successful weight
Vision network consists of major national and regional retail
management: food, body, mind. You can meet with your
locations as well as independent ophthalmologists and
consultant in person at a local center. Or you can enjoy the
optometrists. You and your eligible dependents can receive
ease of the Jenny Craig At Home program.
discounts on laser vision correction services through the TLC/TruVision network.
For more great deals or to learn more about Blue365, visit blue365deals.com/BCBSIL.
Life Time®' Fitness
Life Time Fitness offers a total health fitness experience no
matter your fitness level, interests, schedule or budget. For
Save on digital hearing aids through TruHearing. Get a
new members, Life Time Fitness offers a $0 enrollment fee
hearing test at no extra charge when performed to fit a
when you sign up online.*
hearing aid. Enjoy a 45-day,money-back guarantee and a three-year warranty. Also get a choice of hearing aid styles at
Procter & Gamble (P&G) Dental Products
a number of price levels and enough batteries to last a year
when you buy a hearing aid.
Get savings on dental packages containing the latest in Oral B®' power toothbrushes and Crest®' products. The dental packages from P&G can help you improve the health of your teeth and gums. Packages may contain items such as an electric toothbrush, mouth rinse, floss, and many more.
The relationship between these vendors and Blue Cross and Blue Shield of Illinois (BCBSIL) is that of independent contractors.
* Proof of Blue Cross and Blue Shield of Illinois coverage is needed. The $0 enrollment fee offer is only for new members who enroll online at blue365deals.com/BCBSIL.
A $35 administrative fee applies to all memberships. Monthly dues and taxes may also apply. Members' prices, dues and fees may change at any time. Offer expires September 1, 2013. Other rules may apply. Always check with the Life Time Fitness club in your area for the most up-to-date offer. Offer not available in Minnesota.
Blue365 is a discount program only for BCBSIL members. This is NOT insurance. Some of the services offered through this program may be covered under your health plan. Please check your benefit booklet or call the customer service number on the back of your ID card for specific benefit facts. Use of Blue365 does not change your monthly payment, nor do costs of the services or products count toward any maximums and/or plan deductibles. Discounts are only given through vendors who take part in this program. BCBSIL does not guarantee or make any claims or recommendations about the program's services or products. You may want to talk to your doctor before using these services and products. BCBSIL reserves the right to stop or change this program at any time without notice.
Life Points: Rewards for Healthy Living
Well onTarget understands how hard it can be to maintain a healthy lifestyle. Sometimes you may need a little motivation. That's why we offer Life Points1 to keep you climbing toward your wel ness goals.
With the Life Points program, you will be able to earn points by regularly participating in a range of healthy activities. You can then redeem your points for popular health and wellness merchandise and services.
Rewarding Healthy Behavior
Sample activities that help you earn Life Points include:
• Completing the onmywayTM2 Health Assessment (once every six months)
• Taking all 12 lessons of the onmytime Self-Directed Courses
• Tracking progress in the online tools on the Liveon Member Wellness Portal
• Signing up for the Fitness Program3
• Adding weekly Fitness Program visits to your routine
• Achieving Self-directed Course milestones: Baseline, 30 days, 60 days, 90 days, 180 days
Life Points and Well onTarget feature convenient online tools and personalized services that help support, inform and motivate you on a journey to wel ness.
Service mark of Health Care Service Corporation, a Mutual Legal Reserve CompanyOnlife Health is an independent company that provides wellness services for the Well onTarget program.
1 Life Points Program Rules are subject to change without prior notice. See the Program Rules on the Liveon Member Wellness Portal for further information. Your company may have
additional reward programs in place to encourage you to take advantage of certain preventive care and wellness activities or for making healthy changes. Check your employee benefits.
2 onmyway is a registered mark of Onlife Health.
3 Healthways, Inc. is an independent contractor which administers the Prime Network of fitness centers. The Prime Network is made up of independently-owned and managed fitness centers.
Enhanced Member Experience
The Liveon Member Wel ness Portal gives you access to all the interactive tools and programs you need to start racking up Life Points. Check out the online Shopping Mall with an expanded array of rewards to help motivate you to earn more points.
Life Points offers you many new features:
Instant recognition of points
Real-time granting of points4 gives you with instant notice of your healthy efforts.
Easily manage your points
The interactive portal makes it easier to understand how many points are available to be earned. You can also track the total number of points earned year-to-date. All of your point data will be displayed on one screen.
Get more Life Points
The Life Points program gives you the option to purchase more points to supplement your balance to redeem a larger reward.
Expanded selection of rewards
Redeem your hard-earned points in an expanded online Shopping Mall. Reward categories include Apparel, Books, Health & Personal Care, Jewelry, Electronics, Music and Sporting Goods. In addition, there are more redemption levels so you can earn a reward more quickly.
4 Does not include Life Points earned from the Fitness Program and Biometric Screenings activities.
Health Care Reform
The Affordable Care Act:
Preventive Services at 100%
1 of 4
Preventive Care Services Covered
can be found at: www.healthcare.gov/news/
Without Cost-sharing — Without
Copay, Coinsurance or Deductible
• BCBSIL will use reasonable medical management
techniques to determine any coverage limitations
The Affordable Care Act requires non-grandfathered
on the service, including the frequency, method,
health plans and policies to provide coverage for
treatment or setting for the service, and the use
"preventive care services"1 without cost-sharing
of an out-of-network provider.
(such as coinsurance, deductible or copayment), when the member uses a network provider.
Services may include screenings, immunizations, and other types of care, as recommended by the
Plans that are "grandfathered," meaning plans
federal government.
that had at least one individual enrolled on March 23, 2010, and have not made certain
Blue Cross and Blue Shield of Illinois (BCBSIL) is
changes since that date to cause a loss of
committed to implementing coverage changes to
grandfathered status, are not required to
meet ACA requirements as well as the needs and
implement some of the new requirements
expectations of our members.
of the Affordable Care Act, including the requirement to cover preventive services with
General Highlights of
no cost-sharing.
For more information about grandfathered
• Applies to group health plans including insured
health plans visit this BCBSIL web site:
and self-insured plans, as well as individual and
family policies.
• Preventive services are to be covered without
any cost-sharing when using a network provider. Cost-sharing can still be required when using
Preventive Care Services
a provider that is not in the BCBSIL provider
to Be Offered Without Copay,
Coinsurance or Deductible
• New requirements can be issued at any
time. As new or updated preventive care
Evidence-based preventive services: The list of
recommendations or guidelines are issued,
ACA required preventive services includes those
employers and insurers have one year to
that are recommended and rated "A" or "B"
implement the new guidelines unless otherwise
specified by the government.2
• Plans that cover preventive services in addition
Routine vaccinations: A list of immunizations
to those required may apply cost-sharing
recommended by the Advisory Committee on
requirements for the additional services.
Immunization Practices of the Centers for Disease
• The regulation references preventive care
Control and Prevention are included in the rule.
services with an A or B rating as outlined by
They are considered routine for use with children,
the United States Preventive Services Task Force
adolescents and adults, and range from childhood
(USPSTF).1 They are listed in this fact sheet and
immunizations to periodic tetanus shots for adults.
Publication Date: 12/11/12
The Affordable Care Act: Preventive Services at 100%
2 of 4
Prevention for children: The rule includes
cost-sharing requirements may not be imposed
preventive care guidelines for children from birth
with respect to the office visit.
to age 21 developed by the Health Resources
• If a recommended preventive item or service
and Services Administration with the American
is not billed separately from an office visit
Academy of Pediatrics. Services include regular
and the primary purpose of the office visit is
pediatrician visits, developmental assessments,
not preventive care, then cost-sharing may be
immunizations, and screening and counseling to
applied to the office visit.
address obesity.
Covered Preventive Care Services1
Prevention for women: The regulation mandates
certain preventive care measures for women.
Depending on the particular health plan, coverage
These recommendations will be in place until
may be provided for the following preventive
new requirements for prevention for women are
services without cost-sharing.1 This list may not
issued by the USPSTF or appear in comprehensive
include all of a particular plan's covered services.
guidelines supported by the Health Resources and
BCBSIL members can call Customer Service at the
number on their member ID card for details on how these benefits apply to their coverage and the
most up-to-date list of covered preventive services,
BCBSIL's Focus on Prevention
including those paid without any cost-sharing.
Laying the groundwork for a healthy tomorrow means disease prevention and early detection.
Children and Adolescents
Well-child exam
Many chronic diseases and conditions can be prevented and/or managed through early
Examples of services included as part of a well-
detection. Preventive screenings are an important
child exam include history and physical exam,
way to track your health and avoid chronic
measurements of height, weight and body mass
conditions before they become more serious.
index (BMI), hearing screening4, vision acuity test5, developmental and behavioral assessments,
BCBSIL encourages you to take full advantage
prescription of fluoride if water source is deficient
of your preventive care benefits and other
in fluoride, evaluation of need for a dentist visit,
available wellness resources. After completing
counseling about health risks such as sexually
a health screening, take appropriate steps to
transmitted infections, and obesity counseling.
improve your health. Talk with your physician about ways to improve your health. There is no
better time than now to get started – and head
• Diphtheria, Tetanus, Pertussis
off potential health problems before they begin.
• Haemophilus influenzae type B• Hepatitis A
Billing and Office Visits
• Hepatitis B• Human Papillomavirus (HPV)
• If a recommended preventive service or item
• Influenza (Flu)
is billed separately from an office visit, then cost-sharing may be applied to the office visit.
• Measles, Mumps, Rubella
• If a recommended preventive item or service is
• Meningococcal
not billed separately from an office visit and
the primary purpose is preventive care, then
• Inactivated Poliovirus
Publication Date: 12/11/12
The Affordable Care Act: Preventive Services at 100%
3 of 4
• Varicella (Chickenpox)
• Blood pressure screening
• Cholesterol screening
• Screening for hearing loss,
• Colorectal cancer screenings using
hypothyroidism, sickle cell disease and
fecal occult blood testing,
phenylketonuria (PKU) in newborns
sigmoidoscopy or colonoscopy3
• Hematocrit or hemoglobin screening
• Depression screening
• Obesity screening
• Diabetes screening for adults with
high blood pressure
• Lead screening
• HIV screening
• Dyslipidemia screening for children
at higher risk of lipid disorder
• Obesity screening
• Tuberculin testing
• Sexually transmitted infection (STI)
screenings (chlamydia, gonorrhea, syphilis)
• Depression screening
• Screening for sexually transmitted
infections (STIs)
• Alcohol misuse
• HIV screening
• Cervical dysplasia screening
• Obesity• Prevention of sexually transmitted
infections (STIs)
• Gonorrhea preventive medication for
• Tobacco use and cessation
eyes of all newborns
• Use of aspirin to prevent cardiovascular disease
• Use of folic acid
Examples of services included as part of a
• Abdominal Aortic Aneurysm screening
preventive exam include history and physical
Women Only
exam, measurements of height, weight and body
• Annual well woman visit
mass index (BMI).
• Breast cancer screening/ Screening
• Cervical cancer screening including Pap smear
• Osteoporosis screening
• Human Papillomavirus (HPV)
• Genetic counseling and evaluation
for BRCA testing where family history is
• Influenza (Flu)
associated with an increased risk
• Measles, Mumps, Ruebella
• Human Papillomavirus (HPV) DNA test
• Meningococcal
• Counseling related to
chemoprevention of breast cancer
• Tetanus, Diphtheria, Pertussis
• Breastfeeding9
• Varicella (chickenpox)
• Domestic violence counseling
• Contraception6
Publication Date: 12/11/12
The Affordable Care Act: Preventive Services at 100%
4 of 4
1 ACA requires non-grandfathered health plans and policies
to provide coverage for preventive care services without
Depending on your particular health plan,
cost-sharing only when the member uses a network provider.
coverage without cost-sharing may expand to
This includes preventive care services with an A or B rating as
outlined by the United States Preventive Services Task Force as
include the following contraceptive services
when provided by a health care provider in
• Evidence-based items/services rated A or B in the current
recommendations of the U.S. Preventive Services Task Force
the BCBSIL network.
• Routine immunizations for children, adolescents and adults
recommended by the Advisory Committee on Immunization
• Prescription7 – One or more products
Practices of the Centers for Disease control and prevention
within the categories approved by the FDA
• Evidence-informed preventive care and screenings for
infants, children, and adolescents in the comprehensive
for use as a method of contraception
guidelines of the Health Resources and Services
• Over-the-counter – Contraceptives available
• Evidence-based preventive care and screenings for women
approved by the FDA for women (foam,
described in the comprehensive guidelines of the Health
Resources and Services Administration
sponge, female condoms) when prescribed
For a listing of these services visit
• The morning after pill
2 New requirements can be issued at any time. Plans/policies
have one year from issuance to add the new benefit. New
• Medical devices such as IUD, diaphragm,
requirements on women's preventive services were released by
cervical cap and contraceptive implants
the U.S. Department of Health and Human Services on
Aug. 1, 2011. Non-grandfathered plans/policies are required
• Female sterilization8
to cover these services beginning with plan/policy years starting
on or after Aug. 1, 2012.
For more information about Women's Preventive
3 Anesthesia also covered as preventive4
Services download this BCBSIL Fact Sheet at
Further evaluation recommended as a result of a hearing
screening test is not considered preventive and may not be
covered at 100%.
Vision acuity test to detect amblyopia (lazy eye), strabismus
(cross eye), and defects in visual acuity in children younger than
age 5 years. Normal vision screening and further evaluation
recommended as a result of an acuity test are not considered
preventive and may not be covered as preventive.
Specifically for Pregnant Women
Under federal guidelines, certain religious employers may
not be required to cover contraceptive services. Also,
religious-affiliated employers meeting certain criteria may
• Alcohol misuse screening and counseling
qualify for a temporary enforcement safe harbor period which
doesn't require them to cover the recommended contraceptive
services for one year.
• Anemia screening
7 Prescription coverage for contraception may vary according
to the terms and conditions of your health plan's pharmacy
• Bacteriuria screening
benefit. Please call the customer service number on the member
ID card for coverage details.
• Rh Incompatibility screening
8 Certain restrictions may apply; there might be copay,
coinsurance or deductible in some cases – call the number on
• Gestational diabetes screening
your member ID card for more information. Hysterectomies are
not considered part of the women's preventive care benefit.
• Hepatitis B screening
• Breastfeeding specialist/nurse practitioner with state-
recognized certification who is in your provider network
• Screenings for Sexually Transmitted
• Breastfeeding support and counseling by a trained
Infections (STIs) including chlamydia,
in-network provider while you are pregnant and/or after
you've given birth
gonorrhea, and syphilis
• Manual breast pump1010 Electronic and hospital-grade pumps will not be covered with
• Tobacco use and cessation counseling
no cost-sharing.
This information is a high-level summary and for general informational purposes only. The information is not comprehensive and does not constitute legal, tax, compliance or other advice or guidance.
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Publication Date: 12/11/12
Notice Regarding Your Benefits
This notice is to inform you that for plan years beginning on or after September 23, 2010, Blue Cross and Blue Shield of Illinois (BCBSIL) will administer your benefits in accordance with the terms of your policy and applicable provisions of the Affordable Care Act. BCBSIL will send you an amendment to your policy once it has been approved by the Illinois Department of Insurance.
If you have questions, please contact the customer service number on the back of your identification card.
Group – IL HMO Notification for Highlight Sheets Rev 3 092210
The HMOs of Blue Cross and Blue Shield of Illinois
BlueAdvantage HMO
300 East Randolph, Chicago, IL 60601 Member Services: (800) 892-2803 www.bcbsil.com
2013 Description of Coverage
Cicero Public School Dist #99
B56722 0000 /8888
The Managed Care Reform and Patient Rights Act of 1999 established rights for enrollees in health care plans. These rights cover the following:
• What emergency room visits will be paid for by your health care plan. • How specialists (both in and out of network) can be accessed. • How to file complaints and appeal health care plan decisions, including external independent
• How to obtain information about your health care plan, including general information about its
financial arrangements with providers.
You are encouraged to review and familiarize yourself with these subjects and the other benefit
information in the attached Description of Coverage Worksheet. SINCE THE DESCRIPTION OF
COVERAGE IS NOT A LEGAL DOCUMENT, for full benefit information please refer to your
contract or certificate, or contact your health care plan at (800) 892-2803. In the event of any
inconsistency between your Description of Coverage and contract or certificate, the terms of the contract
or certificate will control.
For general assistance or information, please contact the Illinois Department of Financial and
Professional Regulation – Division of Insurance, Office of Consumer Health Insurance at (877) 527-
9431 or in writing to either of the following addresses:
320 West Washington Street
100 West Randolph Street, Suite 15-100
Springfield, IL 62767-0001
Chicago, IL 60601-3251
You may also contact the department online at http://www.idfpr.com. (Please be aware that the Office of Consumer Health Insurance will not be able to provide specific plan information. For this type of information you should contact your health care plan directly.)
Description of Coverage
Your Doctor
Choose a medical group and primary care physician (PCP) for
each member of your family from our directory or Web site.
Each female member may select a Woman's Principal Health
Care Provider (WPHCP) in addition to her PCP. A member's
PCP and WPHCP must have a referral arrangement with each
other. All care must be provided or coordinated by your PCP,
WPHCP or medical group/Independent Practice Association
(IPA).
Annual Deductible
Out-of-Pocket Maximum
Individual $1,500/calendar year
(excludes drugs, vision,
$3,000/calendar year
durable medical equipment and prosthetics)
Lifetime Maximums
Pre-existing Condition Limitations
Health Care
In the Hospital
Description of Coverage
Plan Covers
Number of Days of Inpatient Care
Room & Board
private or semi-private room
Surgeon's Fees
Doctor's Visits
Medications
Other Miscellaneous Charges
Emergency Care
Emergency Services
(medical conditions with acute symptoms
covered services performed
of sufficient severity such that a prudent
in a hospital emergency room
layperson could reasonably expect the
in or out of area. Copay, if
absence of medical attention to result in
any, waived if admitted.
serious jeopardy of the person's health,
serious impairment to bodily functions or
serious dysfunction to any bodily organ or
Emergency Post-stabilization Services
primary care physician
covered if approved by PCP
* HMO pays 100 percent of covered charges after member's copayment, if any, is paid.
Health Care
In the Doctor's Office
Description of Coverage
Plan Covers
Doctor's Office Visit (copayment covers
primary care physician
the visit and all covered services provided)
Routine Physical Exams
Diagnostic Tests and X-rays
Allergy Treatment & Testing
Wellness Care
Medical Services
hospital facility
Outpatient Surgery
Maternity Care
copay, if any, for 1st visit only 100%*
Infertility Services
based on your group policy
100%* if covered $25
unlimited visits
Non-Serious Mental
unlimited visits
Substance Abuse/
Chemical Dependency
unlimited visits
Serious Mental Health
Outpatient Rehabilitation Services
(includes, but is not limited to, physical,
60 visits combined/CY
occupational or speech therapy)
Outpatient Speech Therapy
(for Pervasive Developmental Disorder only)
* HMO pays 100 percent of covered charges after member's copayment, if any, is paid.
Health Care
Other Services
Description of Coverage
Plan Covers
Durable Medical Equipment
Prosthetic Devices
Ambulance Service
Coordinated Home Care
(excludes custodial care)
Prescription Drug –
up to 34 day supply
Prescription Drug –
▫ up to 90 day supply
▫ visit www.bcbsil.com
or call Member Services for information on the 90
day pharmacy network
Dental Services
see limitations, pages 6-7
one every 12 months
Vision Care
based on your group policy
*HMO pays 100 percent of covered charges after member's copayment, if any, is paid.
Service Area
services or supplies to the extent payments or benefits for such services are provided by or
The HMO Illinois and BlueAdvantage HMO
available from the local, state or federal
service areas include the Illinois counties of
government (for example, Medicare) whether
Boone, Christian, Cook, DeKalb, DuPage, Fulton,
or not those payments or benefits are received;
Greene, Grundy, Iroquois, Kane, Kankakee,
except, however, this exclusion shall not be
Kendall, Lake, LaSalle, Lee, Livingston, Logan,
applicable to medical assistance benefits under
Macoupin, Mason, McHenry, Menard, Monroe,
Article V, VI or VII of the Illinois Public Aid
Morgan, Ogle, Peoria, Sangamon, Stark, St. Clair,
Code or similar legislation of any state,
Stephenson, Tazewell, Whiteside, Williamson,
benefits provided in compliance with the Tax
Will, Winnebago and Lake county in Indiana. The
Equity and Fiscal Responsibility Act or as
HMO Illinois service area also includes Kenosha
otherwise provided by law.
county in Wisconsin. Please note: Some employer groups may have different service areas (see your
6. Services or supplies rendered to you as the
employer for details) and the service area is
result of an injury caused by another person to
subject to change.
the extent that you have collected damages for
such injury and that the Plan has provided benefits for the services or supplies rendered
Exclusions and Limitations
in connection with such injury.
To receive benefits, all care must be provided or
7. Services or supplies that do not meet accepted
coordinated by the member's Primary Care
standards of medical or dental practice
Physician (PCP) or Woman's Principal Health
including, but not limited to, services which
Care Provider (WPHCP) or medical
are investigational in nature.
group/Independent Practice Association (IPA),
8. Custodial care services.
except substance abuse/chemical dependency, vision care and hospital emergency care benefits,
9. Long Term Care services.
which are available at contracting providers
10. Respite Care Services, except as specifically
without a PCP referral.
mentioned under Hospice Care Benefits.
Below is a summary list of exclusions and
11. Services or supplies rendered because of
limitations. Your plan may have specific
behavioral, social maladjustment, lack of
exclusions and limitations not included on this list
discipline or other antisocial actions, which are
– check Your Health Care Benefit Program
not specifically the result of mental illness.
Certificate.
12. Special education therapy, such as music
therapy or recreational therapy.
Exclusions
13. Cosmetic surgery and related services and
1. Services or supplies that are not specifically
supplies unless correcting congenital
listed in Your Health Care Benefit Program
deformities or conditions resulting from
accidental injuries, tumors or disease.
2. Services or supplies that were not ordered by
14. Services or supplies received from a dental or
your primary care physician or Woman's
medical department or clinic maintained by an
Principal Health Care Provider, except as
employer, labor union or other similar person
explained in the Certificate.
3. Services or supplies received before your
15. Services or supplies for which you are not
coverage began or after the date your coverage
required to make payment or would have no
legal obligation to pay if you did not have this or similar coverage.
4. Services or supplies for which benefits have
been paid under any Workers' Compensation
16. Charges for failure to keep a scheduled visit or
Law or other similar laws.
for completion of a claim form or charges for transferring medical records.
5. Services or supplies that are furnished to you
by the local, state or federal government and
17. Personal hygiene, comfort or convenience
Limitations
items commonly used for purposes that are not
In addition to the exclusions noted, the following
medical in nature, such as air conditioners,
limitations apply:
humidifiers, physical fitness equipment,
televisions or telephones.
1. Benefits for oral surgery are limited to:
18. Special braces, splints, specialized equipment,
• surgical removal of completely bony
appliances, ambulatory apparatus or battery
controlled implants.
• excision of tumors or cysts from the jaws,
19. Prosthetic devices, special appliances or
cheeks, lips, tongue, roof or floor of the
surgical implants unrelated to the treatment of
disease or injury, for cosmetic purposes or for the comfort of the patient.
• surgical procedures to correct accidental
injuries of the jaws, cheeks, lips, tongue,
20. Nutritional items such as infant formula,
roof or floor of the mouth,
weight-loss supplements, over-the-counter food substitutes and non-prescription vitamins
• excision of exostoses of the jaws and hard
and herbal supplements.
palate (provided that this procedure is not done in preparation for dentures or other
21. Blood derivatives which are not classified as
drugs in the official formularies.
• treatment of fractures of the facial bone,
22. Marriage counseling.
• external incision and drainage of cellulitis,
• incision of accessory sinuses, salivary
24. Inpatient and Outpatient Private-Duty Nursing
glands or ducts, and
• reduction of, dislocation of or excision of
25. Routine foot care, except for persons
the temporomandibular joints.
diagnosed with diabetes.
2. Benefits for treatment of dental injury due to
26. Maintenance occupational therapy,
accident are limited to treatment of sound
maintenance physical therapy, and
maintenance speech therapy.
3. Benefits for outpatient rehabilitative therapy
27. Maintenance care.
are limited to therapy which is expected to
28. Self-management training, education and
result in significant improvement within two
medical nutrition therapy.
months in the condition for which it is rendered.
29. Services or supplies which are rendered for the
care, treatment, filling, removal, replacement
4. Family planning benefits are not available for
or artificial restoration of the teeth or
repeating or reversing sterilization.
structures directly supporting the teeth.
5. Benefits for elective abortion are limited to
30. Treatment of temporomandibular joint
two per lifetime and are not covered under all
syndrome with intraoral prosthetic devices or
any other method which alters vertical
6. Benefits for infertility, when covered, will not
dimension or treatment of temporomandibular
be provided for the following:
joint dysfunction not caused by documented organic joint disease or physical trauma.
• Reversal of voluntary sterilization.
However, in the event a voluntary
31. Services or supplies rendered for human organ
sterilization is successfully reversed,
or tissue transplants, except as stated in the
benefits will be provided if your diagnosis
Certificate.
meets the definition of "infertility",
32. Hearing aids, except as stated in the
• Services or supplies rendered to a
surrogate, except those costs for
33. Wigs (also referred to as cranial protheses).
procedures to obtain eggs, sperm or
embryos from you, will be covered if you
11. Vision exams are limited to one per 12 month
choose to use a surrogate,
period. Vision coverage does not include benefits for:
• selected termination of an embryo in cases
where the mother's life is not in danger,
• recreational sunglasses
• cryo-preservation or storage of sperm, eggs
• orthoptics, vision training, subnormal
or embryos, except for those procedures
vision aids, aniseikonic lenses or
which use a cryo-preserved substance
• non-medical costs of an egg or sperm
• additional charges for tinted, photo-
sensitive or anti-reflective lenses beyond the benefit allowance for regular lenses
• travel costs for travel within 100 miles of
the covered person's home or which is not
• replacement of lenses, frames or contact
medically necessary or which is not
lenses, which are lost or broken unless
required by the plan,
such lenses, frames or contact lenses would otherwise be covered according to
• infertility treatments which are determined
the benefit period limitations
to be investigational, in writing, by the American Society for Reproductive
12. Durable Medical Equipment rental is covered
Medicine or American College of
up to the price of purchase.
Obstetrics and Gynecology, and
13. Mental health and chemical dependency
• Infertility treatment rendered to your
treatment benefits may be limited – see your
dependents under the age of 18.
Certificate.
7. Benefits for ambulance service are limited to
14. Rehabilitation therapy benefits may be limited
certified ground ambulance, except for human
– see your Certificate.
organ transplants.
15. Maternity inpatient hospital benefits are
8. Human organ transplants must be performed at
limited to 48 hours after birth for vaginal
a plan-approved center for human organ
deliveries and 96 hours after birth for cesarean
transplants and benefits do not include organ
deliveries, unless a longer stay is medically
transplants and/or services or supplies
rendered in connection with an organ transplant which are investigational as
Pre-certification and Utilization Review
determined by the appropriate technological body; drugs which are investigational; storage
All benefits are provided or coordinated by your
fees; services provided to any individual who
PCP or WPHCP. Therefore, certification by the
is not the recipient or actual donor, unless
member is not required. Utilization review is
otherwise specified in this provision; cardiac
conducted by your medical group/IPA, not by the
rehabilitation services when not provided to
HMO. To ensure fair and consistent decisions
the transplant recipient immediately following
regarding medical care, the HMOs of Blue Cross
discharge from a hospital for transplant
and Blue Shield of Illinois require medical
surgery; or travel time or related expenses
groups/IPAs to use nationally recognized
incurred by a provider.
utilization review criteria.
9. Hospice benefits are only available for persons
having a life expectancy of one year or less.
10. Prescription drug benefits, when covered, do
not include drugs used for cosmetic purposes; any devices or appliances; any charges
incurred for administration of drugs; or refills if the prescription is more than one year old.
Primary Care Physician (PCP) Selection
Continuity of Treatment
Each member must join a contracting medical
(Transition of Care)
group/IPA and select a PCP affiliated with that
If a physician you are currently obtaining services
medical group/IPA to provide and coordinate care.
from leaves the HMO network, you have the right
Each female member may also choose an
to request transition of care benefits. To qualify
OB/GYN to be her Woman's Principal Health
for transition of care services, you must currently
Care Provider (WPHCP). A member's PCP and
be undergoing a course of evaluation and/or
WPHCP must have a referral arrangement with
medical treatment or be in the second or third
each other. A member has access to her WPHCP
trimester of pregnancy. The ongoing evaluation
as often as needed without a PCP referral.
and/or medical treatment concerns a condition or
Members may change PCPs/WPHCPs – refer to
disease that requires repeated health care services
the Member Handbook or Certificate for
under a physician's treatment plan, with the
instructions and exceptions. Listings of
potential for changes in a therapeutic regimen.
contracting providers are available in the printed
HMO directory or online at www.bcbsil.com.
Transitional services may be authorized for up to 90 days from the date the physician terminated
Access to Specialty Care
from the network. Authorization of services
If clinically appropriate, your PCP or WPHCP will
depends on the physician's agreement to comply
refer you to a specialist, usually within the same
with contractual requirements and submit a
medical group as your PCP. If the member's
detailed treatment plan, including reimbursement
preferred network specialist does not have a
from the HMO at specified rates and adherence to
referral arrangement with your PCP/WPCHP, you
the HMO's quality assurance requirements,
may choose a new PCP/WPCHP with whom the
policies and procedures. All care must be
specialist has such an arrangement. You can ask
transitioned to your new HMO PCP in the medical
your PCP for a standing referral for conditions that
group/IPA after the transition period has ended.
require ongoing care from a specialist physician.
Coverage will be provided only for benefits
Standing referrals may be made for a specified
outlined in your Certificate.
number of visits or a time period up to one year.
Specialist copays may differ, depending on plan
Existing members: Submit a written Transition of
Care request within 30 days of receiving notice of the termination of the physician or medical
Out-of-Area Coverage
When you are out of state, urgent care and hospital
New members: Submit a written Transition of
emergency room services are available through a
Care request within 15 days after your eligibility
network of contracting Blue Cross and Blue
effective date. When submitting the transition of
Shield providers. When you are out of state for a
care form prior to your effective date, please
minimum of 90 consecutive days, guest
include a copy of the signed application and/or
membership may be arranged in participating
confirmation of enrollment with the HMO.
communities throughout the U.S. with the Guest
Membership Coordinator.
Submit the request to:
Financial Responsibility
Blue Cross and Blue Shield of Illinois Customer Assistance Unit, Transition of Care
You are responsible for copayments at time of
300 East Randolph Street, 23rd Floor
service, as shown in the Description of Coverage.
Chicago, IL 60601
You are also responsible for payment for care not provided or coordinated by your PCP or WPHCP,
except where otherwise noted. You should contact
Include the following information:
your employer's benefit administrator to confirm
• Policyholder's name and work/home
the level of your contribution to the premium.
• Group and ID numbers
• Chosen medical group site
PCP and any other health care provider involved in the matter will receive the same verbal and
• Chosen PCP name, address and phone/fax
written notices.
• Current treating physician
Non-clinical Appeal
• Clinical diagnosis
A non-clinical appeal concerns an adverse decision of an inquiry, complaint or action by the
• Presenting clinical condition (if applicable)
HMO, its employees or its independent
• Reason for transition of care request
contractors that has not been resolved to your
• Expected effective date with the HMO or
satisfaction. A non-clinical appeal relates to
new medical group/IPA (if applicable)
administrative health care services that include (but are not limited to) membership, access, claim
You will be notified within 15 business days of
payment, denial of benefits, out-of-area benefits
the outcome of your Transition of Care request.
and coordination of benefits with another health carrier.
Appeals Process
You can file an appeal by writing to the HMO or
To begin a Level I appeal, notify Member
calling Member Services.
Services by telephone or in writing that you want to pursue a non-clinical appeal. The HMO will
Non-urgent Clinical Appeal
send you a written confirmation within five
After the appeal is received, the HMO Level II
business days of receiving your request. If your
Appeal Committee will request any additional
appeal can be resolved with existing information,
information needed to evaluate your appeal and
the HMO will inform you of its decision within 30
make a decision about your appeal within 15 days
after receiving the required information.
If additional information is needed from either you
You will be informed in advance that you, or
or your medical group/IPA, the HMO will request
someone representing you, have the right to
that it be provided within five business days. The
appear before the Committee either in person, via
appeal decision will be made within 30 business
conference call or some other method. You will
days. When the decision cannot be made within 30
also receive a verbal notification of the HMO's
business days, due to circumstances beyond the
decision. A written notification will be sent within
HMO's control, the HMO will inform you in
five business days of the appeal determination.
writing of the delay. A decision will be made on
Your representative (if any), your PCP and any
or before the 45th business day of receiving the
other health care provider involved in the matter
will receive the same verbal and written notices.
If the appeal is denied, you will be notified that
Urgent Clinical Appeal
your case is being referred to a Level II review. You or a representative has the right to appear in
After the appeal is received, the HMO Level II
person, via conference call or some other method.
Appeal Committee will request any additional
After receiving your Level II appeal, the HMO
information needed to evaluate your appeal and
will notify you in writing at least five business
make a decision about your appeal and notify you
days before the Level II Appeals Committee
by phone within 24 hours – or no later than three
meets. You will receive the Committee's decision
calendar days – of the initial receipt of the clinical
in writing within five business days of the meeting
appeal request. You will be informed in advance
and within 30 business days of beginning the
that you, or someone representing you, have the
Level II appeal process.
right to appear before the Committee either in
person, via conference call or some other method. You will also receive a verbal notification of the HMO's decision. A written notification will be sent within two business days of the appeal determination. Your representative (if any), your
ANY ENROLLEE NOT SATISFIED WITH THE PLAN'S RESOLUTION OF ANY CLINICAL APPEAL, APPEAL OR COMPLAINT MAY APPEAL THE FINAL PLAN DECISION TO THE DIVISION OF INSURANCE, CONSUMER SERVICES SECTION, THROUGH ONE OF THE FOLLOWING LOCATIONS:
• 100 West Randolph Street, Suite 15-100
Chicago, IL 60601-3251
• 320 West Washington Street,
Springfield, IL 62767-0001
You may also contact the Division of Insurance by phone or online at:
• (877) 527-9431
• http://www.idfpr.com.
IMPORTANT: External review determinations
might not be appealable through the Division of
Insurance.
Members have the right to request information on,
the financial relationships between the HMO and
any health care provider; the percentage of
copayments, deductibles and total premiums spent
on health care; and HMO administrative expenses.
For any additional information concerning this
Description of Coverage, call the HMO's toll-
free number at (800) 892-2803.
To receive a Description of Coverage specific to
your benefits, call (800) 892-2803 or return the
enclosed pre-paid card.
In the event of any inconsistency between your
Description of Coverage and contract or
certificate, the terms of the contract or
Certificate shall control.
A Division of Health Care Service Corporation, a
Mutual Legal Reserve Company, an Independent
Licensee of the Blue Cross and Blue Shield
Association
The HMOs of Blue Cross and Blue Shield of Illinois
HMO Illinois
300 East Randolph, Chicago, IL 60601 Member Services: (800) 892-2803 www.bcbsil.com
2013 Description of Coverage
Cicero Public School Dist #99
H56722 0000 / 8888
The Managed Care Reform and Patient Rights Act of 1999 established rights for enrollees in health care plans. These rights cover the following:
• What emergency room visits will be paid for by your health care plan. • How specialists (both in and out of network) can be accessed. • How to file complaints and appeal health care plan decisions, including external independent
• How to obtain information about your health care plan, including general information about its
financial arrangements with providers.
You are encouraged to review and familiarize yourself with these subjects and the other benefit
information in the attached Description of Coverage Worksheet. SINCE THE DESCRIPTION OF
COVERAGE IS NOT A LEGAL DOCUMENT, for full benefit information please refer to your
contract or certificate, or contact your health care plan at (800) 892-2803. In the event of any
inconsistency between your Description of Coverage and contract or certificate, the terms of the contract
or certificate will control.
For general assistance or information, please contact the Illinois Department of Financial and
Professional Regulation – Division of Insurance, Office of Consumer Health Insurance at (877) 527-
9431 or in writing to either of the following addresses:
320 West Washington Street
100 West Randolph Street, Suite 15-100
Springfield, IL 62767-0001
Chicago, IL 60601-3251
You may also contact the department online at http://www.idfpr.com. (Please be aware that the Office of Consumer Health Insurance will not be able to provide specific plan information. For this type of
information you should contact your
health care plan directly.)
Description of Coverage
Your Doctor
Choose a medical group and primary care physician (PCP) for
each member of your family from our directory or Web site.
Each female member may select a Woman's Principal Health
Care Provider (WPHCP) in addition to her PCP. A member's
PCP and WPHCP must have a referral arrangement with each
other. All care must be provided or coordinated by your PCP,
WPHCP or medical group/Independent Practice Association
(IPA).
Annual Deductible
Out-of-Pocket Maximum
Individual $1500/calendar year
(excludes drugs, vision,
$3000/calendar year
durable medical equipment and prosthetics)
Lifetime Maximums
Pre-existing Condition Limitations
Health Care
In the Hospital
Description of Coverage
Plan Covers
Number of Days of Inpatient Care
Room & Board
private or semi-private room
Surgeon's Fees
Doctor's Visits
Medications
Other Miscellaneous Charges
Emergency Care
Emergency Services
(medical conditions with acute symptoms
covered services performed
of sufficient severity such that a prudent
in a hospital emergency room
layperson could reasonably expect the
in or out of area. Copay, if
absence of medical attention to result in
any, waived if admitted.
serious jeopardy of the person's health,
serious impairment to bodily functions or
serious dysfunction to any bodily organ or
Emergency Post-stabilization Services
primary care physician
covered if approved by PCP
* HMO pays 100 percent of covered charges after member's copayment, if any, is paid.
Health Care
In the Doctor's Office
Description of Coverage
Plan Covers
Doctor's Office Visit (copayment covers
primary care physician
the visit and all covered services provided)
Routine Physical Exams
Diagnostic Tests and X-rays
Allergy Treatment & Testing
Wellness Care
Medical Services
hospital facility
Outpatient Surgery
Maternity Care
copay, if any, for 1st visit only 100%*
Infertility Services
based on your group policy
100%* if covered $30
unlimited visits
Non-Serious Mental
unlimited visits
Substance Abuse/
Chemical Dependency
unlimited visits
Serious Mental Health
Outpatient Rehabilitation Services
(includes, but is not limited to, physical,
60 visits combined/CY
occupational or speech therapy)
Outpatient Speech Therapy
(for Pervasive Developmental Disorder only)
* HMO pays 100 percent of covered charges after member's copayment, if any, is paid.
Health Care
Other Services
Description of Coverage
Plan Covers
Durable Medical Equipment
Prosthetic Devices
Ambulance Service
Coordinated Home Care
(excludes custodial care)
Prescription Drug –
up to 34 day supply
Prescription Drug –
▫ up to 90 day supply
▫ visit www.bcbsil.com
or call Member Services for information on the 90
day pharmacy network
Dental Services
see limitations, pages 6-7
one every 12 months
Vision Care
based on your group policy
*HMO pays 100 percent of covered charges after member's copayment, if any, is paid.
Service Area
services or supplies to the extent payments or benefits for such services are provided by or
The HMO Illinois and BlueAdvantage HMO
available from the local, state or federal
service areas include the Illinois counties of
government (for example, Medicare) whether
Boone, Christian, Cook, DeKalb, DuPage, Fulton,
or not those payments or benefits are received;
Greene, Grundy, Iroquois, Kane, Kankakee,
except, however, this exclusion shall not be
Kendall, Lake, LaSalle, Lee, Livingston, Logan,
applicable to medical assistance benefits under
Macoupin, Mason, McHenry, Menard, Monroe,
Article V, VI or VII of the Illinois Public Aid
Morgan, Ogle, Peoria, Sangamon, Stark, St. Clair,
Code or similar legislation of any state,
Stephenson, Tazewell, Whiteside, Williamson,
benefits provided in compliance with the Tax
Will, Winnebago and Lake county in Indiana. The
Equity and Fiscal Responsibility Act or as
HMO Illinois service area also includes Kenosha
otherwise provided by law.
county in Wisconsin. Please note: Some employer groups may have different service areas (see your
6. Services or supplies rendered to you as the
employer for details) and the service area is
result of an injury caused by another person to
subject to change.
the extent that you have collected damages for
such injury and that the Plan has provided benefits for the services or supplies rendered
Exclusions and Limitations
in connection with such injury.
To receive benefits, all care must be provided or
7. Services or supplies that do not meet accepted
coordinated by the member's Primary Care
standards of medical or dental practice
Physician (PCP) or Woman's Principal Health
including, but not limited to, services which
Care Provider (WPHCP) or medical
are investigational in nature.
group/Independent Practice Association (IPA),
8. Custodial care services.
except substance abuse/chemical dependency, vision care and hospital emergency care benefits,
9. Long Term Care services.
which are available at contracting providers
10. Respite Care Services, except as specifically
without a PCP referral.
mentioned under Hospice Care Benefits.
Below is a summary list of exclusions and
11. Services or supplies rendered because of
limitations. Your plan may have specific
behavioral, social maladjustment, lack of
exclusions and limitations not included on this list
discipline or other antisocial actions, which are
– check Your Health Care Benefit Program
not specifically the result of mental illness.
Certificate.
12. Special education therapy, such as music
therapy or recreational therapy.
Exclusions
13. Cosmetic surgery and related services and
1. Services or supplies that are not specifically
supplies unless correcting congenital
listed in Your Health Care Benefit Program
deformities or conditions resulting from
accidental injuries, tumors or disease.
2. Services or supplies that were not ordered by
14. Services or supplies received from a dental or
your primary care physician or Woman's
medical department or clinic maintained by an
Principal Health Care Provider, except as
employer, labor union or other similar person
explained in the Certificate.
3. Services or supplies received before your
15. Services or supplies for which you are not
coverage began or after the date your coverage
required to make payment or would have no
legal obligation to pay if you did not have this or similar coverage.
4. Services or supplies for which benefits have
been paid under any Workers' Compensation
16. Charges for failure to keep a scheduled visit or
Law or other similar laws.
for completion of a claim form or charges for transferring medical records.
5. Services or supplies that are furnished to you
by the local, state or federal government and
17. Personal hygiene, comfort or convenience
Limitations
items commonly used for purposes that are not
In addition to the exclusions noted, the following
medical in nature, such as air conditioners,
limitations apply:
humidifiers, physical fitness equipment,
televisions or telephones.
1. Benefits for oral surgery are limited to:
18. Special braces, splints, specialized equipment,
• surgical removal of completely bony
appliances, ambulatory apparatus or battery
controlled implants.
• excision of tumors or cysts from the jaws,
19. Prosthetic devices, special appliances or
cheeks, lips, tongue, roof or floor of the
surgical implants unrelated to the treatment of
disease or injury, for cosmetic purposes or for the comfort of the patient.
• surgical procedures to correct accidental
injuries of the jaws, cheeks, lips, tongue,
20. Nutritional items such as infant formula,
roof or floor of the mouth,
weight-loss supplements, over-the-counter food substitutes and non-prescription vitamins
• excision of exostoses of the jaws and hard
and herbal supplements.
palate (provided that this procedure is not done in preparation for dentures or other
21. Blood derivatives which are not classified as
drugs in the official formularies.
• treatment of fractures of the facial bone,
22. Marriage counseling.
• external incision and drainage of cellulitis,
• incision of accessory sinuses, salivary
24. Inpatient and Outpatient Private-Duty Nursing
glands or ducts, and
• reduction of, dislocation of or excision of
25. Routine foot care, except for persons
the temporomandibular joints.
diagnosed with diabetes.
2. Benefits for treatment of dental injury due to
26. Maintenance occupational therapy,
accident are limited to treatment of sound
maintenance physical therapy, and
maintenance speech therapy.
3. Benefits for outpatient rehabilitative therapy
27. Maintenance care.
are limited to therapy which is expected to
28. Self-management training, education and
result in significant improvement within two
medical nutrition therapy.
months in the condition for which it is rendered.
29. Services or supplies which are rendered for the
care, treatment, filling, removal, replacement
4. Family planning benefits are not available for
or artificial restoration of the teeth or
repeating or reversing sterilization.
structures directly supporting the teeth.
5. Benefits for elective abortion are limited to
30. Treatment of temporomandibular joint
two per lifetime and are not covered under all
syndrome with intraoral prosthetic devices or
any other method which alters vertical
6. Benefits for infertility, when covered, will not
dimension or treatment of temporomandibular
be provided for the following:
joint dysfunction not caused by documented organic joint disease or physical trauma.
• Reversal of voluntary sterilization.
However, in the event a voluntary
31. Services or supplies rendered for human organ
sterilization is successfully reversed,
or tissue transplants, except as stated in the
benefits will be provided if your diagnosis
Certificate.
meets the definition of "infertility",
32. Hearing aids, except as stated in the
• Services or supplies rendered to a
surrogate, except those costs for
33. Wigs (also referred to as cranial protheses).
procedures to obtain eggs, sperm or
embryos from you, will be covered if you
11. Vision exams are limited to one per 12 month
choose to use a surrogate,
period. Vision coverage does not include benefits for:
• selected termination of an embryo in cases
where the mother's life is not in danger,
• recreational sunglasses
• cryo-preservation or storage of sperm, eggs
• orthoptics, vision training, subnormal
or embryos, except for those procedures
vision aids, aniseikonic lenses or
which use a cryo-preserved substance
• non-medical costs of an egg or sperm
• additional charges for tinted, photo-
sensitive or anti-reflective lenses beyond the benefit allowance for regular lenses
• travel costs for travel within 100 miles of
the covered person's home or which is not
• replacement of lenses, frames or contact
medically necessary or which is not
lenses, which are lost or broken unless
required by the plan,
such lenses, frames or contact lenses would otherwise be covered according to
• infertility treatments which are determined
the benefit period limitations
to be investigational, in writing, by the American Society for Reproductive
12. Durable Medical Equipment rental is covered
Medicine or American College of
up to the price of purchase.
Obstetrics and Gynecology, and
13. Mental health and chemical dependency
• Infertility treatment rendered to your
treatment benefits may be limited – see your
dependents under the age of 18.
Certificate.
7. Benefits for ambulance service are limited to
14. Rehabilitation therapy benefits may be limited
certified ground ambulance, except for human
– see your Certificate.
organ transplants.
15. Maternity inpatient hospital benefits are
8. Human organ transplants must be performed at
limited to 48 hours after birth for vaginal
a plan-approved center for human organ
deliveries and 96 hours after birth for cesarean
transplants and benefits do not include organ
deliveries, unless a longer stay is medically
transplants and/or services or supplies
rendered in connection with an organ transplant which are investigational as
Pre-certification and Utilization Review
determined by the appropriate technological body; drugs which are investigational; storage
All benefits are provided or coordinated by your
fees; services provided to any individual who
PCP or WPHCP. Therefore, certification by the
is not the recipient or actual donor, unless
member is not required. Utilization review is
otherwise specified in this provision; cardiac
conducted by your medical group/IPA, not by the
rehabilitation services when not provided to
HMO. To ensure fair and consistent decisions
the transplant recipient immediately following
regarding medical care, the HMOs of Blue Cross
discharge from a hospital for transplant
and Blue Shield of Illinois require medical
surgery; or travel time or related expenses
groups/IPAs to use nationally recognized
incurred by a provider.
utilization review criteria.
9. Hospice benefits are only available for persons
having a life expectancy of one year or less.
10. Prescription drug benefits, when covered, do
not include drugs used for cosmetic purposes; any devices or appliances; any charges
incurred for administration of drugs; or refills if the prescription is more than one year old.
Primary Care Physician (PCP) Selection
Continuity of Treatment
Each member must join a contracting medical
(Transition of Care)
group/IPA and select a PCP affiliated with that
If a physician you are currently obtaining services
medical group/IPA to provide and coordinate care.
from leaves the HMO network, you have the right
Each female member may also choose an
to request transition of care benefits. To qualify
OB/GYN to be her Woman's Principal Health
for transition of care services, you must currently
Care Provider (WPHCP). A member's PCP and
be undergoing a course of evaluation and/or
WPHCP must have a referral arrangement with
medical treatment or be in the second or third
each other. A member has access to her WPHCP
trimester of pregnancy. The ongoing evaluation
as often as needed without a PCP referral.
and/or medical treatment concerns a condition or
Members may change PCPs/WPHCPs – refer to
disease that requires repeated health care services
the Member Handbook or Certificate for
under a physician's treatment plan, with the
instructions and exceptions. Listings of
potential for changes in a therapeutic regimen.
contracting providers are available in the printed
HMO directory or online at www.bcbsil.com.
Transitional services may be authorized for up to 90 days from the date the physician terminated
Access to Specialty Care
from the network. Authorization of services
If clinically appropriate, your PCP or WPHCP will
depends on the physician's agreement to comply
refer you to a specialist, usually within the same
with contractual requirements and submit a
medical group as your PCP. If the member's
detailed treatment plan, including reimbursement
preferred network specialist does not have a
from the HMO at specified rates and adherence to
referral arrangement with your PCP/WPCHP, you
the HMO's quality assurance requirements,
may choose a new PCP/WPCHP with whom the
policies and procedures. All care must be
specialist has such an arrangement. You can ask
transitioned to your new HMO PCP in the medical
your PCP for a standing referral for conditions that
group/IPA after the transition period has ended.
require ongoing care from a specialist physician.
Coverage will be provided only for benefits
Standing referrals may be made for a specified
outlined in your Certificate.
number of visits or a time period up to one year.
Specialist copays may differ, depending on plan
Existing members: Submit a written Transition of
Care request within 30 days of receiving notice of the termination of the physician or medical
Out-of-Area Coverage
When you are out of state, urgent care and hospital
New members: Submit a written Transition of
emergency room services are available through a
Care request within 15 days after your eligibility
network of contracting Blue Cross and Blue
effective date. When submitting the transition of
Shield providers. When you are out of state for a
care form prior to your effective date, please
minimum of 90 consecutive days, guest
include a copy of the signed application and/or
membership may be arranged in participating
confirmation of enrollment with the HMO.
communities throughout the U.S. with the Guest
Membership Coordinator.
Submit the request to:
Financial Responsibility
Blue Cross and Blue Shield of Illinois Customer Assistance Unit, Transition of Care
You are responsible for copayments at time of
300 East Randolph Street, 23rd Floor
service, as shown in the Description of Coverage.
Chicago, IL 60601
You are also responsible for payment for care not provided or coordinated by your PCP or WPHCP,
except where otherwise noted. You should contact
Include the following information:
your employer's benefit administrator to confirm
• Policyholder's name and work/home
the level of your contribution to the premium.
• Group and ID numbers
• Chosen medical group site
PCP and any other health care provider involved in the matter will receive the same verbal and
• Chosen PCP name, address and phone/fax
written notices.
• Current treating physician
Non-clinical Appeal
• Clinical diagnosis
A non-clinical appeal concerns an adverse decision of an inquiry, complaint or action by the
• Presenting clinical condition (if applicable)
HMO, its employees or its independent
• Reason for transition of care request
contractors that has not been resolved to your
• Expected effective date with the HMO or
satisfaction. A non-clinical appeal relates to
new medical group/IPA (if applicable)
administrative health care services that include (but are not limited to) membership, access, claim
You will be notified within 15 business days of
payment, denial of benefits, out-of-area benefits
the outcome of your Transition of Care request.
and coordination of benefits with another health carrier.
Appeals Process
You can file an appeal by writing to the HMO or
To begin a Level I appeal, notify Member
calling Member Services.
Services by telephone or in writing that you want to pursue a non-clinical appeal. The HMO will
Non-urgent Clinical Appeal
send you a written confirmation within five
After the appeal is received, the HMO Level II
business days of receiving your request. If your
Appeal Committee will request any additional
appeal can be resolved with existing information,
information needed to evaluate your appeal and
the HMO will inform you of its decision within 30
make a decision about your appeal within 15 days
after receiving the required information.
If additional information is needed from either you
You will be informed in advance that you, or
or your medical group/IPA, the HMO will request
someone representing you, have the right to
that it be provided within five business days. The
appear before the Committee either in person, via
appeal decision will be made within 30 business
conference call or some other method. You will
days. When the decision cannot be made within 30
also receive a verbal notification of the HMO's
business days, due to circumstances beyond the
decision. A written notification will be sent within
HMO's control, the HMO will inform you in
five business days of the appeal determination.
writing of the delay. A decision will be made on
Your representative (if any), your PCP and any
or before the 45th business day of receiving the
other health care provider involved in the matter
will receive the same verbal and written notices.
If the appeal is denied, you will be notified that
Urgent Clinical Appeal
your case is being referred to a Level II review. You or a representative has the right to appear in
After the appeal is received, the HMO Level II
person, via conference call or some other method.
Appeal Committee will request any additional
After receiving your Level II appeal, the HMO
information needed to evaluate your appeal and
will notify you in writing at least five business
make a decision about your appeal and notify you
days before the Level II Appeals Committee
by phone within 24 hours – or no later than three
meets. You will receive the Committee's decision
calendar days – of the initial receipt of the clinical
in writing within five business days of the meeting
appeal request. You will be informed in advance
and within 30 business days of beginning the
that you, or someone representing you, have the
Level II appeal process.
right to appear before the Committee either in
person, via conference call or some other method. You will also receive a verbal notification of the HMO's decision. A written notification will be sent within two business days of the appeal determination. Your representative (if any), your
ANY ENROLLEE NOT SATISFIED WITH THE PLAN'S RESOLUTION OF ANY CLINICAL APPEAL, APPEAL OR COMPLAINT MAY APPEAL THE FINAL PLAN DECISION TO THE DIVISION OF INSURANCE, CONSUMER SERVICES SECTION, THROUGH ONE OF THE FOLLOWING LOCATIONS:
• 100 West Randolph Street, Suite 15-100
Chicago, IL 60601-3251
• 320 West Washington Street,
Springfield, IL 62767-0001
You may also contact the Division of Insurance by phone or online at:
• (877) 527-9431
• http://www.idfpr.com.
IMPORTANT: External review determinations
might not be appealable through the Division of
Insurance.
Members have the right to request information on,
the financial relationships between the HMO and
any health care provider; the percentage of
copayments, deductibles and total premiums spent
on health care; and HMO administrative expenses.
For any additional information concerning this
Description of Coverage, call the HMO's toll-
free number at (800) 892-2803.
To receive a Description of Coverage specific to
your benefits, call (800) 892-2803 or return the
enclosed pre-paid card.
In the event of any inconsistency between your
Description of Coverage and contract or
certificate, the terms of the contract or
Certificate shall control.
A Division of Health Care Service Corporation, a
Mutual Legal Reserve Company, an Independent
Licensee of the Blue Cross and Blue Shield
Association
Participating Provider Option PPO
This provides only highlights of the benefit plan. After enrollment, members will receive a Certificate that more fully describes the terms of coverage.
(In-Network)
(Out-of-Network)
Lifetime Benefit Maximum
Per individual
UNLIMITED
Individual Coverage Deductible
Program deductible does not apply to services that have a copayment.
Family Coverage Deductible
The family deductible maximum is equal to three individual deductibles.
Individual Coverage Out-of-Pocket Expense (OPX) Limit
The amount of money that any individual wil have to pay toward covered health care expenses during any one
calendar year. The fol owing items wil not be applied to the out-of-pocket expense limit:
Deductibles
Copayments
Reductions in benefits due to non-compliance with utilization management program requirements
Charges that exceed the eligible charge or the Schedule of Maximum Al owances (SMA)
Services that are asterisked below (*)
Family Coverage Out-of-Pocket Expense (OPX) Limit
Prescription Drug Card (Retail and Mail Service)
Please refer to the Outpatient Prescription Drug Highlights Sheet for the covered benefits.
Physician Office Visits
One copayment per day when you receive services from a Family Practice, Internal Medicine, OB/GYN, or
$20 copay,
70% after deductible
Pediatrician. Surgeries, therapies and certain diagnostic procedures performed in a physician's office may be
then 100%
subject to the deductible and/or coinsurance, including mental health and substance abuse services.
One copayment per day when you receive services from a specialist. Surgeries, therapies and certain
$30 copay,
70% after deductible
diagnostic procedures performed in a physician's office may be subject to the deductible and/or coinsurance.
then 100%
Well Care (all ages)
Includes benefits for routine physical examinations, immunizations and routine diagnostic tests.
$20 copay,
70% after deductible
Limited to one physical exam plus one gynecological exam per calendar year.
then 100%
Maternity Services
Copayment applies to first prenatal visit (per pregnancy). Al other maternity physician covered services are
$20 copay,
70% after deductible
paid the same as Medical / Surgical Services.
then 100%
Medical / Surgical Services
Coverage for surgical procedures, inpatient visits, therapies, al ergy injections or treatments, and certain
90% after deductible
70% after deductible
diagnostic procedures as wel as other physician services.
Hospital Admission Deductible
Per admission, per individual
Inpatient Hospital Services
Coverage includes services received in a hospital, skil ed nursing facility, coordinated home care and hospice,
90% after deductible
70% after deductible
including mental health and substance abuse services. Room al owances based on the hospital's most common semi-private room rates.
Outpatient Hospital Services
Coverage for services includes, but is not limited to outpatient or ambulatory surgical procedures, x-ray, lab
90% after deductible
70% after deductible
tests, chemotherapy, radiation therapy, renal dialysis, and mammograms performed in a hospital or ambulatory surgical center, including mental health and substance abuse services. Routine mammograms performed in an in-network outpatient hospital setting are payable at 100%, no deductible wil apply.
Outpatient Emergency Care (Accident or Illness)
The copayment applies to both in- and out-of-network emergency room visits. The copayment is waived if the
80%, no deductible
member is admitted to the hospital.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 1 of 2
Participating Provider Option PPO
Muscle Manipulation Services*
Coverage for spinal and muscle manipulation services provided by a physician or chiropractor. Related office
90% after deductible
70% after deductible
visits are paid the same as other Physician Office Visits.
20 visits per calendar year.
Therapy Services – Speech, Occupational and Physical
Coverage for services provided by a physician or therapist. Outpatient -Unlimited for Physical, Occupational
90% after deductible
70% after deductible
30 Visit Limit, Speech 20 Visit Limit per calendar year)
Temporomandibular Joint (TMJ) Dysfunction and Related Disorders
90% after deductible
70% after deductible
Other Covered Services
Private duty nursing (50 Visits per calendar year)
• Ambulance services
80% after deductible
Naprapathic services* - $1,000 maximum per calendar year
• Medical supplies
Blood and blood components
See paragraph below regarding Schedule of Maximum Al owances (SMA).
Does not apply to any out-of-pocket limits
Durable Medical Equipment (DME) is a covered benefit. Please refer to Certificate for details.
Optometrists, Orthotic, Prosthetic, Pedorthists, Registered Surgical Assistants, Registered Nurse First Assistants and Registered Surgical Technologists are covered
providers. Please refer to Certificate for details.
Discounts on Eye Exams, Prescription Lenses and Eyewear
Members can present their ID cards to receive discounts on eye exams, prescription lenses and eyewear. To locate participating vision providers, log into Blue Access® for Members
(BAM) at www.bcbsil.com/member and click on the BlueExtras Discount Program link.
Blue Care Connection (BCC)
When members receive covered inpatient hospital services, outpatient mental health and substance abuse services (MHSA), coordinated home care, skil ed nursing facility or private duty
nursing from a participating provider, the member wil be responsible for contacting either the BCC or MHSA preauthorization line, as applicable. You must cal one day prior to any
hospital admission and/or outpatient MH/SA service or within 2 business days after an emergency medical or maternity admission. Please refer to your benefit booklet for information
regarding benefit reductions based on failure to contact the applicable preauthorization line. Note: Outpatient MHSA preauthorization is effective for services on or after January 1,
2011 or upon your group plan renewal date in 2011 and thereafter.
Schedule of Maximum Allowances (SMA)
The Schedule of Maximum Al owances (SMA) is not the same as a Usual and Customary fee (U&C). Blue Cross and Blue Shield of Il inois' SMA is the maximum al owable charge for
professional services, including but not limited to those listed under Medical/Surgical and Other Covered Services above. The SMA is the amount that professional PPO providers have
agreed to accept as payment in ful . When members use PPO providers, they avoid any balance bil ing other than applicable deductible, coinsurance and/or copayment. "Please refer to
your certificate booklet for the definition of Eligible Charge and Maximum Al owance regarding Providers who do not participate in the PPO Network.".
To Locate a Participating Provider: Visit our Web site at www.bcbsil.com/providers and use our Provider Finder® tool.
In addition, benefits for covered individuals who live outside Il inois wil meet al extraterritorial requirements of those states, if any, according to the group's funding arrangements.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 2 of 2
Prescription Drug Card
P r o g r a m B a s i c s
P a y m e n t O p t i o n s
(Generic / Preferred Brand /
Non-Preferred Brand)
Copayments are for up to a 34-day supply at a contracting retail pharmacy, including
$10/ $40 / $60
diabetic supplies: blood glucose test strips, diagnostic agents used with urine testing, glucagon.
Mail Service
Maintenance medications are available for up to a 90-day supply and are subject to the
$20/$80/$120
appropriate copayment amount, including diabetic supplies: blood glucose test strips, diagnostic agents used with urine testing, glucagon.
Available at retail and mail service at the appropriate copayment level based on drug
As indicated above
Available at retail and mail service at the appropriate copayment level.
As indicated above
*effective 1/1/10, members with a BCBSIL drug card wil have lancets pay at a $0 copay
Reimbursement for non-contracting pharmacies
Benefits at a non-contracting pharmacy are covered at 75% of the amount that would have been paid at a contracting pharmacy minus the appropriate copayment amount.
Prior Authorization and Step Therapy Program Requirements
Your physician may be required to obtain authorization from BCBSIL in order to receive benefits for certain drugs that have a potential for misuse. Examples of these
medications include: rheumatoid arthritis, growth hormone, hepatitis C, and anabolic steroids. In the event prior authorization is not obtained, you wil be responsible for the first
$1,000 or 50% of the Eligible Charge, whichever is less.
If you are required to receive prior authorization for certain medications under the step therapy program, you need to first try a proven, cost effective medication before
progressing to a more costly treatment, if necessary. After a member has a prescription history for a lower-cost alternative medication, coverage wil automatical y be provided
for a more costly medication included in the step therapy program, if the physician and member determine that it is necessary for the member to try a drug included in the
program. As an alternative to receiving prior authorization for a drug included in the step therapy program, or paying the entire cost of the drug out-of-pocket, a member along
with his/her physician may select another drug, which is not part of the program.
Prescription drugs categories are added to the program and are subject to change periodical y. To verify which drugs are included in your prescription drug benefit program,
contact the Pharmacy Program customer service number, which is located on the back of your ID card. You can also visit the BCBSIL Web site at www.bcbsil.com and log on
to Blue Access® for Members to find additional information.
What is the Blue Cross and Blue Shield of Illinois formulary?
The BCBSIL formulary is a regularly updated list of preferred drugs determined by our Pharmacy and therapeutic Committee, a national panel comprised of individuals who
hold a medical or pharmacy degree who evaluate U.S. Food and Drug Administration (FDA)-approved drugs based on comparative clinical standards, including efficacy,
safety, uniqueness and cost-effectiveness. The formulary includes al generic drugs and select group of brand drugs. The BCBSIL formulary is "open," meaning that benefits
are payable for drugs that are not on the formulary, but are subject to the highest copayment level.
How can I find out if a drug is on the formulary, and if it is a generic or a brand name drug?
As part of the enrol ment literature, members may receive a list of some of the most commonly prescribed formulary drugs. If a particular drug does not appear on the list,
members can:
Refer to the pocket edition of the BCBSIL formulary.
Visit the BCBSIL Web site at www.bcbsil.com.
Discuss the most appropriate drug therapy with their physician or pharmacist. Using generic drugs whenever possible wil help save money.
How can I find a contracting pharmacy?
Visit our Web site at www.bcbsil.com to find a contracting pharmacy.
Rev. 07 / 2013
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 1 of 1
Health Care Service Corporation, A Mutual Legal Reserve Company
Fort Dearborn Life Insurance Company, A Stock Life Insurance Company
Notice of Information Practices
This description of the Information Practices of Health Care Service Corporation (HCSC) a Mutual Legal Reserve Company and Fort
Dearborn Life Insurance Company (FDL), a Stock Life Insurance Company, (collectively referred to herein as "we," "our" or "us"),
is provided to you in accordance with the requirements of the Illinois Insurance Information and Privacy Protection Law.
Collection of Information
In order to properly underwrite and administer your insurance coverage, we must collect a certain amount of necessary and helpful
information. The amount and type of information may vary depending on the amount and type of coverage applied for, but in general
we will be seeking information about your age, occupation, physical condition and health history.
You are our most important source of information, but we may also collect or verify information by contacting medical professionals andinstitutions which have provided care to you or members of your family proposed for coverage, employers and business associates, friendsand neighbors, and other insurance companies you have applied to. We may collect information by exchanges of correspondence, by phoneor by personal contact.
Circumstances of Disclosure
In some circumstances, we may make disclosures of personal or privileged information to third parties without your authorization.
Following is a description of the types of persons who may receive such information without your authorization and some of the
circumstances that might give rise to such disclosures.
• We might use an unaffiliated organization or person to perform a professional, business or insurance function for us. If, for example, we
hired an independent organization to assist in the administration of a group insurance plan of which you are a participant, informationrelating to your insurance coverage would be disclosed to that organization in order for it to adequately perform its function. This wouldalso be the case with respect to any organization or person, which performs a professional, business or insurance function for us.
• We may disclose information concerning your coverage to our agents and producers in order to provide you with adequate service,
including the updating and improvement of your insurance program.
• We may disclose information to other insurance institutions, agents, insurance-support organizations or self-insurers, which is necessary
(a) to prevent criminal activity, fraud, material misrepresentation or material non-disclosure in connection with insurance transactions, or(b) for either of us or such company to perform its function in connection with an insurance transaction involving you or a member ofyour family insured under your coverage. For example, if you are a participant in an HCSC or FDL group insurance plan, and if you,your spouse or dependents are insured under other group plans, the companies involved may be required to share claims informationpursuant to coordination of benefits provisions in their respective policies. The object, of course, is to make sure that you receive totalbenefits from all companies no greater than the cost of health care received.
• We may disclose information to the Illinois Insurance regulatory authority in connection with its regulation of our business.
• We may disclose information to a law enforcement or governmental authority to protect our interest in preventing or prosecuting the
perpetration of fraud upon us, or if we reasonably believe that illegal activities have been conducted we will also disclose informationwhen permitted or required by law to do so.
• Various industry and professional organizations conduct scientific and actuarial research studies to learn more about the risk experience of
our insureds. Other organizations conduct studies relating to medical research. These studies are purely scientific in nature, never identifyindividuals in their reports, and always maintain information provided in a highly confidential manner. When asked to provide informationto such organizations, we ordinarily will do so because the results of such studies are of benefit to our customers and the public at large.
You will not be individually identified in any report that results from the research, and material that we give to the person or organizationperforming the research will be returned to us or destroyed when it is no longer needed.
• If you are covered under an HCSC and/or FDL group policy, we may disclose information as is reasonably necessary to the group for
purposes of administration of the group policy and to permit the group to audit, review and evaluate the performance of HCSC and FDLunder the group policy.
• We are sometimes approached by persons or organizations that are interested in the opportunity to market products or services to our
customers. When this happens, we may provide some limited information. However, if we want to give information to persons not affiliated with us, we will give you an opportunity to indicate to us that you do want information to be disclosed for this purpose. We willgive information to our affiliates so that our customers may be aware of the insurance products and services offered by our affiliates.
Please understand that the above is intended to describe some of the disclosures which might be made, not disclosures which are always or even often made, in any event, the information disclosed without your authorization will be only as much as reasonably necessary toaccomplish the intended purpose.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Your Right to Access Personal Information
As an individual, you have certain rights in regards to access to recorded personal information, which is reasonably locatable and retrievable.
In order to maintain the security of that information, access will be permitted only after proper identification has been submitted to us.
1. If you have any question about what information we may have on file about you, please write us at the address indicated at the end of
this notice. We will need your complete name, address, date of birth and all policy numbers under which you are insured. Tell us whatinformation you would like to receive. Within 30 days of our receipt of your written request, we will:
a) Inform you of the nature and substance of the recorded personal information in writing, by telephone or by other communication;b) Permit you to see and copy, in person (by appointment only,) the recorded personal information which applies to you or provide
you with copies of this information by mail;
c) Any insurance-support organization that furnished the personal information that has been corrected, amended or deleted.
2. If you disagree with a refusal to correct, amend or delete recorded personal information, you may file a:
a) Concise document setting forth what you think is the correct, relevant or fair information, and a b) Concise statement of the reasons why you disagree with the refusal to correct, amend or delete recorded personal information.
3. If you file either of the statements described above, we will:
a) File the statement with the disputed personal information and provide a means by which anyone reviewing the disputed personal
information will be made aware of the statement and have access to it;
b) In any subsequent disclosure of the recorded personal information that is the subject of disagreement, clearly identify the
information in dispute and provide the statements along with the recorded personal information being disclosed;
c) Furnish the statement to any of the three categories of persons and organizations covered in the preceding point "2."
4. Your rights to correct, amend or delete recorded personal information exist to the extent that the information is collected and maintained
in connection with an insurance transaction. These rights do not extend to information about you that relates to and is collected in connection with or in reasonable anticipation of a claim or civil or criminal processing.
Please understand that the above is intended to describe some of the disclosures which might be made, not disclosures which are always oreven often made. In any event, the information disclosed without your authorization will only be as much as reasonably necessary to accom-plish the intended purpose.
Your Privacy Is Our Concern
Should you have any questions about our procedures or information maintained about you, please contact us at the following address:
Health Care Service Corporation, (A Mutual Legal Reserve Company)
300 East Randolph
Chicago, IL 60601
Attn: SSD – Privacy Act Information
This Important Notice is for coverages provided by Fort Dearborn Life Insurance Company
Fort Dearborn's underwriting process (evaluation and classification of risks) is necessary to assure reasonable cost of insurance and to providea mechanism by which policyholders and certificate holders pay their fair share of the cost. In considering your application, Fort Dearbornconsiders information from various sources, including your own statements, the results of your physical examination (if required), and anyobtained from doctors or medical facilities where you have been treated.
Information regarding your insurability will be treated as confidential. Fort Dearborn, or its reinsurer(s), may, however, make a brief reportthereon to the Medical Information Bureau, Inc. a nonprofit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another Bureau Member Company for life or health insurance coverage,or a claim for benefits is submitted to such a company, the Bureau, upon request, will supply such a company with the information it mayhave in its file.
Upon receipt of a request from you, the Bureau will arrange a disclosure of any information it may have in your file. If you question theaccuracy of the information in the Bureau's file, you may contact the Bureau and seek a correction in accordance with procedures set forthin the Federal Fair Credit Reporting Act. The address of the Bureau's information office is Post Office Box 105, Essex Station, Boston,Massachusetts 02112, telephone number (617) 426-3660.
Fort Dearborn, or its reinsurer(s) may also release information in their file to other life insurance companies to whom you may apply for lifeor health insurance, or to whom a claim for benefits may be submitted.
The purpose of the Bureau is to protect its member and their policyholders from the extra expense created by those who omit or concealinformation relevant to their insurability. Information furnished by the Bureau may serve to alert the company to a need for further investigation but under Bureau rules cannot be used either wholly or partly as the basis for increasing the charge for or denying the issuanceof insurance. Information in the Bureau gives no indication regarding the action taken on an application (i.e., whether accepted standard,accepted with increase premium or declined).
I. Initial Notice About Special Enrollment Rights and Pre-existing
Condition Exclusion Rules in Your Group Health Plan
A federal law called Health Insurance Portability and Accountability Act (HIPAA) requires that we notify you about two very important provisions in the plan. The first is your right to enroll in the plan under its "special enrollment provision" without being considered a late applicant if you acquire a new dependent or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons. Second, this notice advises you of the plan's pre-existing condition exclusion rules that may temporarily exclude coverage for certain pre-existing conditions that you or a member of your family may have. Section I of this notice may not apply to certain self-insured, non-federal governmental plans. Contact your employer or plan administrator for more information.
A. SPECIAl ENRollmENt PRovISIoNS
loss of other Coverage (Excluding medicaid or a State Children's Health Insurance Program) If you are declining
enrollment for yourself or your eligible dependents (including your spouse) because of other health insurance or
group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your
dependents lose eligibility for that other coverage (or if you move out of an HMO service area, or the employer
stops contributing toward your or your dependents' other coverage). However, you must request enrollment within
31 days after your or your dependents' other coverage ends (or move out of the prior plan's HMO service area, or
after the employer stops contributing toward the other coverage).
loss of Coverage For medicaid or a State Children's Health Insurance Program
If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage
or coverage under a state children's health insurance program is in effect, you may be able to enroll yourself and
your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must
request enrollment within 60 days after your or your dependents' coverage ends under Medicaid or a state children's
health insurance program.
New Dependent by marriage, Birth, Adoption, or Placement for Adoption
If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to
enroll yourself and your dependents in this plan. However, you must request enrollment within 31 days after the
marriage, birth, adoption, or placement for adoption.
Eligibility for State Premium Assistance for Enrollees of medicaid or a State Children's Health Insurance Program
If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from
Medicaid or through a state children's health insurance program with respect to coverage under this plan, you may
be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days
after your or your dependents' determination of eligibility for such assistance.
You or your spouse or dependents may also have special enrollment rights in another group health plan at the time a claim is denied as a result of a lifetime limit on all benefits, if you request enrollment within 30 days after the claim has been denied.
to request special enrollment or obtain more information, call Customer Service at the phone number on
the back of your Blue Cross and Blue Shield ID card.
B. PRE-ExIStING CoNDItIoN ExCluSIoN RulES
Most health plans impose pre-existing condition exclusions. This means that if you have a medical condition before coming to our plan you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care or treatment was recommended or received within the six- month period before your enrollment date. Generally, this six-month period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the six-month period ends on the day before the waiting period begins. "Waiting period" generally refers to a delay between the first day of employment and the first day of coverage under the plan. The pre-existing condition exclusion does not apply to pregnancy or to an individual under the age of 19.
This pre-existing condition exclusion may last up to 12 months (18 months if you are a late enrollee) from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period. However, you can reduce the length of this exclusion period by the number of days you had prior "creditable coverage." Most prior health coverage is creditable coverage and can be used to reduce the pre-existing condition exclusion if you have not experienced a break in coverage of at least 63 days. To reduce the 12-month (or 18-month) exclusion period by your creditable coverage, you should give us a copy of any certificates of creditable coverage you have. If you do not have a certificate, but you do have prior health coverage, you have a right to request one from your prior plan or issuers. We will help you obtain one from your prior plan or issuer, if necessary. There are also other ways that you can show you have creditable coverage. Please contact us if you need help demonstrating creditable coverage.
For more information about the pre-existing condition exclusion and creditable coverage rules affecting
your plan, call Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card.
II. Additional Notices
Other federal laws require we notify you of additional provisions of your plan.
NotICES oF RIGHt to DESIGNAtE A PRImARY CARE PRovIDER (FoR NoN-GRANDFAtHERED HEAltH
PlANS oNlY)
For plans that require or allow for the designation of primary care providers by participants or beneficiaries:
If the plan generally requires or allows the designation of a primary care provider, you have the right to designate any
primary care provider who participates in our network and who is available to accept you or your family members. For
information on how to select a primary care provider, and for a list of the participating primary care providers, call
Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card.
For plans that require or allow for the designation of a primary care provider for a child: For children,
you may designate a pediatrician as the primary care provider.
For plans that provide coverage for obstetric or gynecological care and require the designation by a
participant or beneficiary of a primary care provider: You do not need prior authorization from the plan or
from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care
from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional,
however, may be required to comply with certain procedures, including obtaining prior authorization for certain ser-
vices, following a pre-approved treatment plan, or procedures for making referrals.
For a list of participating health care professionals who specialize in pediatrics, obstetrics or gynecology, call
Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card.
HIPAA Noticeof Privacy Practices
This notice describes how medical information about you may be used and disclosed and howyou can get access to this information.
PLEASE REVIEW IT CAREFULLY.
Our Responsibilities
We are required by applicable federal and state law to maintain the privacy of your protected health information. "Protected health
information" (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present
or future physical or mental health or condition and related health care services. We are also required to give you this notice about our
privacy practices, our legal duties, and your rights concerning your PHI. We must follow the privacy practices that are described in this
notice while it is in effect. This notice takes effect November 10, 2008, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all PHIthat we maintain, including PHI we created or received before we made the changes. Before we make a significant change in our privacypractices, we will change this notice and make the new notice available upon request.
For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at theend of this notice.
Uses and Disclosures of Protected Health Information
We use and disclose PHI about you for treatment, payment, and health care operations. Following are examples of the types of uses and
disclosures that we are permitted to make.
Treatment: We may use or disclose your PHI to a physician or other health care provider providing treatment to you. We may use or
disclose your PHI to a health care provider so that we can make prior authorization decisions under your benefit plan.
Payment: We may use and disclose your PHI to make benefit payments for the health care services provided to you. We may disclose
your PHI to another health plan, to a health care provider, or other entity subject to the federal Privacy Rules for their payment purposes.
Payment activities may include processing claims, determining eligibility or coverage for claims, issuing premium billings, reviewing
services for medical necessity, and performing utilization review of claims.
Health Care Operations: We may use and disclose your PHI in connection with our health care operations. Health care operations
include the business functions conducted by a health insurer. These activities may include providing customer services, responding to
complaints and appeals from members, providing case management and care coordination under the benefit plans, conducting medical
review of claims and other quality assessment and improvement activities, establishing premium rates and underwriting rules. In certain
instances, we may also provide PHI to the employer who is the plan sponsor of a group health plan.
We may also in our health care operations disclose PHI to business associates1 with whom we have written agreements containing terms to protect the privacy of your PHI. We may disclose your PHI to another entity that is subject to the federal Privacy Rules and that has a relationship with you for its health care operations relating to quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, case management and care coordination, or detecting or preventing healthcare fraud and abuse.
Joint Operations: We may use and disclose your PHI connected with a group health plan maintained by your plan sponsor with one or
more other group health plans maintained by the same plan sponsor, in order to carry out the payment and health care operations of such
an organized health care arrangement.
1 A "business associate" is a person or entity who performs or assists Blue Cross Blue Shield of Illinois with an activity involving the use or disclosure of medical information that is protected under the Privacy Rules.
On Your Authorization: You may give us written authorization to use your PHI or to disclose it to another person and for the purpose you
designate. If you give us an authorization, you may withdraw it in writing at any time. Your withdrawal will not affect any use or disclosures
permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your PHI
for any reason except those described in this notice. We will make disclosures of any psychotherapy notes we may have only if you
provide us with a specific written authorization or when disclosure is required by law.
Personal Representatives: We will disclose your PHI to your personal representative when the personal representative has been properly
designated by you and the existence of your personal representative is documented to us in writing through a written authorization.
Disaster Relief: We may use or disclose your PHI to a public or private entity authorized by law or by its charter to assist in disaster
relief efforts.
Health Related Services: We may use your PHI to contact you with information about health related benefits and services or about
treatment alternatives that may be of interest to you. We may disclose your PHI to a business associate to assist us in these activities. We
may use or disclose your PHI to encourage you to purchase or use a product or service by face-to-face communication or to provide you
with promotional gifts.
Public Benefit: We may use or disclose your PHI as authorized by law for the following purposes deemed to be in the public interest or benefit:
• as required by law;
• for public health activities, including disease and vital statistic reporting, child abuse reporting, certain Food and Drug Administration
(FDA) oversight purposes with respect to an FDA-regulated product or activity, and to employers regarding work-related illness or injury required under the Occupational Safety and Health Act (OSHA) or other similar laws;
• to report adult abuse, neglect, or domestic violence;
• to health oversight agencies;
• in response to court and administrative orders and other lawful processes;
• to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on
our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person;
• to avert a serious threat to health or safety;
• to the military and to federal officials for lawful intelligence, counterintelligence, and national security activities;
• to correctional institutions regarding inmates; and
• as authorized by and to the extent necessary to comply with state worker's compensation laws.
We will make disclosures for the following public interest purposes, only if you provide us with a written authorization or when disclosureis required by law:
• to coroners, medical examiners, and funeral directors;
• to an organ procurement organization; and
• in connection with certain research activities.
Use and Disclosure of Certain Types of Medical Information: For certain types of PHI we may be required to protect your privacy in ways
more strict than we have discussed in this notice. We must abide by the following rules for our use or disclosure of certain types of your PHI:
• HIV Test Information. We may not disclose the result of any HIV test or that you have been the subject of an HIV test unless required
by law or the disclosure is to you or other persons under limited circumstances or you have given us written permission to disclose.
• Genetic Information. We may not use or disclose your genetic information unless the use or disclosure is made as required by law or
you provide us with written permission to disclose such information.
• Mental Health Information Records. We may not disclose your mental health information records except to you and anyone else
authorized by law to inspect and copy your mental health information records or you provide us with written permission to disclose.
• Alcoholism or Drug Abuse Information. We may not disclose any alcoholism or drug abuse information related to your treatment
in an alcohol or drug abuse program unless the disclosure is allowed or required by law or you provide us with written permission to disclose.
Individual Rights
You may contact us using the information at the end of this notice to obtain the forms described here, explanations on how to submit a
request, or other additional information.
Access: You have the right, with limited exceptions, to look at or get copies of your PHI contained in a designated record set. A "designated
record set" contains records we maintain such as enrollment, claims processing, and case management records. You may request that we
provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make
a request in writing to obtain access to your PHI and may obtain a request form from us. If we deny your request, we will provide you a
written explanation and will tell you if the reasons for the denial can be reviewed and how to ask for such a review or if the denial cannot
be reviewed.
Disclosure Accounting: You have the right to receive a list of instances for the 6-year period, but not before April 14, 2003 in which we
or our business associates disclosed your PHI for purposes, other than treatment, payment, health care operations, or as authorized by you,
and for certain other activities. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-
based fee for responding to these additional requests. We will provide you with more information on our fee structure at your request.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your PHI. We are not required to
agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement we may make
to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. We will not
be bound unless our agreement is in writing.
Confidential Communication: You have the right to request that we communicate with you about your PHI by alternative means or to
alternative locations. You must make your request in writing. This right only applies if the information could endanger you if it is not
communicated by the alternative means or to the alternative location you want. You do not have to explain the basis for your request, but
you must state that the information could endanger you if the communication means or location is not changed. We must accommodate
your request if it is reasonable, specifies the alternative means or location, and provides satisfactory explanation how payments will be
handled under the alternative means or location you request.
Amendment: You have the right, with limited exceptions, to request that we amend your PHI. Your request must be in writing, and it must
explain why the information should be amended. We may deny your request if we did not create the information you want amended
and the originator remains available or for certain other reasons. If we deny your request, we will provide you a written explanation. You
may respond with a statement of disagreement to be attached to the information you wanted amended. If we accept your request to amend
the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the
changes in any future disclosures of that information.
Right to Receive a Copy of the Notice: You may request a copy of our notice at any time by contacting the Privacy Office or by using our
website, www.bcbsil.com. If you receive this notice on our web site or by electronic mail (e-mail), you are also entitled to request a
paper copy of the notice.
Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at
the end of this notice.
If you are concerned that we may have violated your privacy rights, you may complain to us using the contact information listed at theend of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services; see information at itswebsite: www.hhs.gov. If you request, we will provide you with the address to file your complaint with the U.S. Department of Health andHuman Services.
We support your right to the privacy of your PHI. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Contact: Director, Privacy Office
You may also contact us using the
Blue Cross Blue Shield of Illinois
toll-free number located on the back of
your BCBSIL's member identification card.
Chicago, IL 60680-4110
New Prescription Order Form
Mail this form to:
For added service:
Visit www.bcbsil.com
or call 877.357.7463
Dallas, TX 75265-0041
TTY 711Llame la farmacia de PrimeMail en
877.357.7463 o el registro sobre nuestro
sitio del web en www.bcbsil.com
CARD HOLDER INFORMATION
Card Holder's ID
Card Holder's Date of Birth (mm/dd/yyyy)
Card Holder's Last Name
Card Holder's First Name
Patient's Last Name (if different than card holder's last name)
Patient's First Name
Patient's Gender: Male Female
Patient's Date of Birth (mm/dd/yyyy)
Patient's Phone Number
Patient's Permanent Address
Patient's E-mail Address
Contact by: E-mail Phone
DRUG ALLERGIES
HEALTH CONDITIONS
PATIENT'S NEW PRESCRIPTIONS
Drug Name
Physician/Prescriber's Name & Phone Number
Do not fill at this time
Total Number of Prescriptions:
Mail the original physician-signed prescriptions with this completed form. For multiple dependents please use multiple
forms. If more than 3 prescriptions are needed, write the requested information from this table on a separate piece of paper
and enclose with your order. Additional processing time may be required for prescriptions that require physician clarification.
For prescriptions to be filled at a later date, call the customer service number above to activate. CONTINUED ON BACK
SHIPPING INFORMATION
Regular: No charge
Second business day: $15*
Next business day: $22*
charged to you.
Shipping time does not include processing time. Shipping prices are subject to change.
We are unable to ship second business day or next business day orders to PO boxes.
Shipping address must be a physical location.
Alternate Shipping Address (if different than permanent address)
This is a change of address
This is a one time address
Seasonal address from
PAYMENT INFORMATION
Payment is due with each order and may be made by credit card, check or money order. Orders received without payment
may delay processing. There is a $20 returned check charge.
Check or money order
Please make check or money order payable to Prime Therapeutics and
Check Money Order
include your member ID on the memo line. Do not send cash.
Credit card information
To authorize payment by credit card, provide the account number, expiration date and signature. We accept Discover,
MasterCard, VISA and American Express. This card will be used for this and all future orders unless we are notified
otherwise.
Credit Card Number
Use credit card on file, with the last 4 digits of:
Pharmacy law may permit pharmacists to substitute a less expensive FDA-approved generically equivalent medication
for a brand-name medication unless you or your prescriber indicate otherwise. Some health plans require the patient to
pay the difference between generic and brand name cost.
By returning this form to PrimeMail, you consent to the release and use of the patient's health information to the
patient's health plans and health care providers/agents for health benefits management. Prime Therapeutics' use or
disclosure of individually identifiable health information, whether furnished by you or obtained from other sources such
as medical providers, shall be in accordance with federal privacy regulations under HIPAA (Health Insurance Portability
and Accountability Act of 1996).
PrimeMail may contact your physician for clarification and safety purposes, which may result in your physician
prescribing a different, clinically appropriate product.
Blue Cross and Blue Shield of Illinois (BCBSIL) is a Division of Health Care Service Corporation, a Mutual Legal
Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
PrimeMail is a mail-service pharmacy owned and operated by Prime Therapeutics. BCBSIL contracts with
Prime Therapeutics to provide pharmacy benefit management and mail-service pharmacy services. In addition,
contracting pharmacies are contracted through Prime Therapeutics. The relationship between BCBSIL and contracting
pharmacies is that of independent contractors. BCBSIL, as well as several other independent Blue Cross and
Blue Shield Plans, has an ownership interest in Prime Therapeutics.
PrimeMail is a registered trademark of Prime Therapeutics LLC.
3208 IL NEW Prime Therapeutics LLC 06/11
APPLICATION AND POLICY CHANGE
DIRECTIONS FOR COMPLETING APPLICATION FORM
Detach these instructions from the application before beginning. Use black or blue ballpoint pen only. Print neatly.
Do not abbreviate. PRESS HARD.
Complete all fields answering each question as accurately as possible. If you are unsure or have questions about
any of the information requested on this form, please see your GROUP ADMINISTRATOR.
ENROLLEE: Check the reason you are completing this form.
Timely Enrollment: Your first opportunity to enroll after becoming eligible.
Special Enrollment: You are enrolling within 31 days of a special enrollment event as specified in the Federal
HIPAA regulations (e.g., birth, adoption, or placement for adoption, marriage, divorce or involuntary loss of
other coverage).
Late Enrollment: You are enrolling at the time other than when first becoming eligible or after a Special
Enrollment period ends.
COBRA: You are eligible for continuation of your group health coverage.
Retiree: You are eligible for your group health coverage as a retired employee.
Membership Change: Any change to your current membership such as adding dependents, canceling
dependents or changing your benefits. This change may occur outside of Open Enrollment.
Open Enrollment: The period of time offered on a regular basis during which you can elect to enroll in a specific
group health insurance plan or make changes to your current membership.
EFFECTIVE DATE: If known, enter effective date, and your Group, Section and Identification Numbers.
COBRA/IL Continuation: If you are a COBRA/IL Continuation enrollee, enter the start and end date for your
COBRA/IL Continuation benefits. The remaining COBRA/IL Continuation information will be completed by Blue
Cross and Blue Shield of Illinois.
COVERAGE APPLIED FOR: Check all coverages that you are enrolling for based on the plans offered by
your employer. If you previously had Blue Cross coverage, enter the prior Group, Section and Identification Numbers
at the bottom of this section. (If you are enrolling for Family Coverage, be sure to include information on family
members in Section U.) If you are declining coverage, read, complete and sign Sections T and {.
CHANGES TO EXISTING MEMBERSHIP: Check all boxes that apply to change coverage, add or cancel
dependents, or cancel coverage. If you are changing your PCP or WPHCP, circle the reason(s) why at the
bottom of this section.
NOTE: Medical Group/IPA changes are not allowed if a member or dependent is receiving in-hospital care
or is in the third trimester of pregnancy.
To add a dependent, check the appropriate box. Members may add dependents within 31 days of a qualifying
event (e.g., marriage, birth and/or adoption of a child or during open enrollment). Enter the date of the qualifying
event. NOTE: List only those dependents to be added in Section U. If coverage is changing from Individual to
Family, check the appropriate box in Section Y. See your Group Administrator for other requirements to add
dependents.
To cancel a dependent, check the appropriate box. Enter the date the dependent is to be canceled from
coverage. NOTE: List only those dependents to be canceled in Section U. If coverage is changing from Family
to Individual, check the appropriate box in Section Y.
*Fort Dearborn Life is a separate company that does not provide Blue Cross and Blue Shield of Illinois products or services. Fort Dearborn Life is solely responsible for the life and disability coverage provided.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Directions, Page 1
EMPLOYEE INFORMATION: Answer every question that applies to you.
If changing name and/or address, check the appropriate box in Section T and enter your NAME and ADDRESS in
section Y. Be sure that you have completed Section W.
Enter your Social Security and Identification numbers.
Include your employee identification number if you know it.
Your Social Security number is used for internal purposes only.
If you selected HMO coverage in Section R, you must select a Medical Group or IPA and a Primary Care Physician
(PCP) for each person to be covered. You must also select a Primary Care Physician within the selected Medical
Group/IPA for each person to be covered. You may choose a different Medical Group/IPA for each person.
Female members may choose a Woman's Principal Health Care Provider (WPHCP). A WPHCP may be seen for care
without referrals from your PCP, however the PCP and WPHCP must have a referral arrangement with one another.
Until we receive your selected medical group information you are not eligible to receive medical services and your
claims will be denied. Be sure to enter the Medical Group/IPA number, name, PCP number and name.
If you selected CPO or CPO Value Choice, you must select a CPO Network.
If you selected Dental HMO, include your Dental HMO group number and select a Dental HMO office for each
person to be covered.
If you are covered by MEDICARE, enter your HIC number, which is the Medicare claim number on your Medicare
ID card. Enter the start and end dates where they apply for: Medicare A, Medicare B, End Stage Renal Disease
(ESRD) Dialysis, and Disability. The ESRD start date is the day ESRD regular course at dialysis begins, (or the date
of kidney transplant in the case of total renal failure). The disability start date is the date the beneficiary is entitled to
Medicare due to disability.
FAMILY COVERAGE INFORMATION: Answer every question as it applies to your family. If you are changing
existing membership, list only those dependents to be added or canceled.
A) SPOUSE — Enter complete information for your spouse. If you selected HMO coverage in Section R, or your
spouse is covered by Medicare, complete the HMO and Medicare sections as instructed in Section Y.
B) DEPENDENTS — Enter complete information for your child(ren). If you selected HMO coverage in Section R,
or your dependent(s) is covered by Medicare, complete the HMO and Medicare sections as instructed in Section
Y. Space for additional dependents is provided on the second page of this application. If necessary use a separate
piece of paper and attach it to this application.
OTHER INSURANCE INFORMATION: If you have other insurance coverage, enter the information requested
completely. This information will allow for the proper coordination of your health care benefits.
FORT DEARBORN LIFE: If you are enrolling with Fort Dearborn Life, enter the information requested.When listing
the Beneficiary provide both the first and last name, and the relationship to you. List all Beneficiaries that apply. If
necessary use a separate piece of paper and attach it to this application.
SIGNATURE LINE FOR NEW/CHANGING COVERAGE: Please read, date and sign this Section. Your
signature is required.
SIGNATURE LINE IF DECLINING COVERAGE: If you are declining coverage, please read this Section and check
the appropriate box identifying for whom you are declining coverage and the reason. Your signature is required.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Directions, Page 1
APPLICATION AND POLICY CHANGE
PLEASE PRINT — USE BLACK OR BLUE BALLPOINT PEN ONLY — PRESS HARD.
Q ENROLLEE:
) Timely ) Special ) Late
Open Enrollment: ) New Member ) Plan Change ) Add Dependents
W EFFECTIVE DATE: _/ _/ _
E COBRA / Illinois Continuation Section
Employee Status: ) Active Employee ) COBRA Continuation ) IL Continuation ) Retiree, retirement date _/ _/ _
) COBRA: Start Date _/ _/ _ Projected End Date _/ _/ _
) IL Continuation Privilege: Start Date _/ _/ _ Projected End Date _/ _/ _
Previously covered with group as:
) 1. Employee (termination of employment, reduction in hours, other.)
) 3. Dependent (reach age limit, married, no longer full-time student, other.)
) 2. Spouse (divorce from employee, death of employee, other.)
) 4. Spouse and Dependents (divorce from employee, death of employee, other.)
R COVERAGE APPLIED FOR: Check all that apply.**
T CHANGES TO EXISTING MEMBERSHIP: Check all that apply.
After checking coverage applied for or making changes to existing membership, complete Group Number, Section Number, Social Security Number and Name.
) PPO Value Choice
(Check all that apply)
) w/HCA (BlueEdge HMO)
) BlueChoice Select
) CPO Value Choice
) BlueAdvantage HMO
) BlueEdge Select HSA
) HMO Medical Group/IPA
) Terminate Coverage
) w/HCA (BlueEdge HMO)
) Integrated with BCBSIL Vendor
) PCP and/or WPHCP
) Waive Coverage**
) Adoption/Placement
Legal Guardianship
) Integrated with BCBSIL Vendor ) BlueEdge Select HCA
) Out of Service Area Move
) BlueDecision PPO
) From PPO to HMO
) From HMO to PPO
) Individual / Employee ) Employee & Spouse ) Employee & Child(ren) ) Family
) From HMOI to BA HMO
Only list dependents to be added or
Enter Dental Group number if different than Medical Group policy number.
From BA HMO to HMOI
dropped in the Family Coverage
) Dental Group #:
) Medicare Coverage
Information Section U.
) BlueCare Dental PPO
) FDL Beneficiary
) BlueCare Dental HMO (Select your dental office in section 6 and 7 when applicable)
*After checking the appropriate
A. Availability
B. PCP moved office
Fort Dearborn Life
physician change, circle reason:
C. Location
D. PCP added to Network
Previous BC (Illinois) or HMO Membership:
E. Dissatisfied with PCP
F. PCP office/facility undesirable
H. Other _
Group #: Section #:
**If not electing coverage, please read, complete and sign Section
Identification #: _
Y EMPLOYEE INFORMATION: Company Name:
Last Name:
Date of Birth: _/ _/ _
Are You Eligible for Family Coverage: ) No ) Yes
Health Coverage Elected:
) Individual/Employee ) Employee & Spouse ) Employee & Child(ren) ) Family
Gender: ) Male ) Female
Employee Social Security Number: _ — _ — Employee Identification Number (if known):
Telephone No.: Bus.: ( ) Home: ( )
Date of Hire: / /
Dept. No.: Payroll Location: _ Employee Clock No.: _
If HMO: Medical Group/IPA #: _ _ _ _ _ _ _ _ _ _ Medical Group/IPA Name:
WPHCP Medical Group Name: _ _ _ _ _ _ _ _ WPHCP (Physician) #: _ _ _ _ _ _ _ _ _ _ WPHCP (Physician) Name:
The PCP and WPHCP must have a referral arrangement.
If CPO/CPO Value Choice: Network # CO: _ If BlueCare Dental HMO: Office ID#: _
Employment Status: ) Actively at Work ) Retired If retired, retirement date: ) COBRA/IL Continuation
Are you covered under your employer's health care plan and also covered by Medicare?
If Yes, the section below must be completed:
U FAMILY COVERAGE INFORMATION: List All Eligible Dependents.
U A SPOUSE: Date of Birth: _/ _/ _
Last Name (Only If Different):
First Name: _ Social Security Number: _ — _ — _
If HMO: Medical Group/IPA #: _ _ _ _ _ _ _ _ _ _ Medical Group/IPA Name: WPHCP Medical Group/IPA #: _ _ _ _ _ _ _ _ _ _
PCP #: _ _ _ _ _ _ _ _ _ _ PCP Name: _ WPHCP Medical Group Name:
WPHCP (Physician) #: _ _ _ _ _ _ _ _ WPHCP (Physician) Name: If BlueCare Dental HMO: Office ID#:
The PCP and WPHCP must have a referral arrangement.
Is this dependent covered under your employer's health care plan and also covered by Medicare? ) No
) Yes If Yes, the section below must be completed:
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
EMPLOYEE AND DEPENDENT INFORMATION:
Employee Last Name:
Employee First Name:
U FAMILY COVERAGE INFORMATION: List All Eligible Dependents.
U B ) SON ) DAUGHTER: Date of Birth: _/ _/ _
Last Name (Only If Different): First Name:
Social Security Number: _ — _ — _ If HMO: Medical Group/IPA #: _ _ _ _ _ _ _ _ _ _
Medical Group/IPA Name: PCP #: _ _ _ _ _ _ _ _ _ _ PCP Name: WPHCP Medical Group/IPA #: _ _ _ _ _ _ _ _ _ _
WPHCP Medical Group Name: WPHCP (Physician) #: _ _ _ _ _ _ _ _ _ _ WPHCP (Physician) Name:
The PCP and WPHCP must have a referral arrangement.
If BlueCare Dental HMO: Office ID#:
Is this dependent covered under your employer's health care plan and also covered by Medicare? ) No
) Yes If Yes, the section below must be completed:
) SON ) DAUGHTER: Date of Birth: _/ _/ _
Last Name (Only If Different): First Name:
Social Security Number: _ — _ — _ If HMO: Medical Group/IPA #: _ _ _ _ _ _ _ _ _ _
Medical Group/IPA Name: PCP #: _ _ _ _ _ _ _ _ _ _ PCP Name: WPHCP Medical Group/IPA #: _ _ _ _ _ _ _ _ _ _
WPHCP Medical Group Name: WPHCP (Physician) #: _ _ _ _ _ _ _ _ _ _ WPHCP (Physician) Name:
The PCP and WPHCP must have a referral arrangement.
If BlueCare Dental HMO: Office ID#:
Is this dependent covered under your employer's health care plan and also covered by Medicare? ) No
) Yes If Yes, the section below must be completed:
) SON ) DAUGHTER: Date of Birth: _/ _/ _
Last Name (Only If Different): First Name:
Social Security Number: _ — _ — _ If HMO: Medical Group/IPA #: _ _ _ _ _ _ _ _ _ _
Medical Group/IPA Name: PCP #: _ _ _ _ _ _ _ _ _ _ PCP Name: WPHCP Medical Group/IPA #: _ _ _ _ _ _ _ _ _ _
WPHCP Medical Group Name: WPHCP (Physician) #: _ _ _ _ _ _ _ _ _ _ WPHCP (Physician) Name:
The PCP and WPHCP must have a referral arrangement.
If BlueCare Dental HMO: Office ID#:
Is this dependent covered under your employer's health care plan and also covered by Medicare? ) No
) Yes If Yes, the section below must be completed:
I OTHER INSURANCE INFORMATION:
If you or any of your family members have OTHER GROUP COVERAGE, Check all that apply.
) Health: Policy #: _ ) Dental: Policy #: _
) Prescription Drug Coverage:
) Vision: Policy #:
) Hearing: Policy #:
If Yes: Is the other insurance:
) Single Coverage
) Family Coverage
EMPLOYED BY: _ Insured's Name: Date of Birth: _/ _/ _
Insurance Company Name: _ Address: _
City: State: _ Zip: Telephone Number:
O FORT DEARBORN LIFE:
Employee Job Title: _ Class Type:
Basic Salary: $
) Hourly ) Weekly ) Semi-Monthly ) Monthly ) Annually
Check Coverage Applied For: Term Life/AD&D: ) No ) Yes $ _ Dependent Life: ) No ) Yes $ _ Weekly Income: ) No ) Yes $ _
Supplemental Life:
) No ) Yes $ _ Long Term Disability: ) No ) Yes $ _ ) Voluntary AD&D: $ ) Single ) Family
Permanent Life Insurance:
) No ) Yes $ If Yes: ) Automatic Premium Loan
) Replaces An Existing Policy
BENEFICIARY: Note: If more than one Beneficiary, interest will be equal unless otherwise indicated.
Last Name: _ First Name: Relationship: _
I APPLY FOR COVERAGE AS INDICATED ABOVE, for which I am or may become eligible under the agreement with Health Care Service Corporation (providing hospital and medical, dental coverage and health maintenance
P coverage), and/or Fort Dearborn Life Insurance Company (providing the life and disability insurance) (the Company). I have read the above statements and represent they are true and complete to the best of my knowledge.
I authorize my employer/group to deduct from my pay and remit any required contribution for the cost of said coverage. This authorization is to remain in effect until the Company is notified by me in writing to the contrary. I understand that the benefits listed in the Certificate(s) will be available subject to the Terms and Conditions thereof effective as listed in the Certificate(s) of Coverage.
Date Signed: _ / _ / _ Signature of Applicant: _
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided
{ that you request enrollment within 31 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and
your dependents, provided that you request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.
I DO NOT WISH TO ENROLL at this time and understand that the opportunity to enroll at any future time will be subject to such arrangements as may be made with the Company.
Not enrolling for:
) My spouse
) My spouse and dependents
) My dependents
) Myself, my spouse and my dependents
) Covered under spouse's employer-based health insurance plan (complete "Other Insurance Information" in I) ) Covered under a Medicare supplement plan
) Other (please explain)
Date Signed: _ / _ / _ Signature of Applicant: _
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Source: http://www.cicd99.edu/uploaded/Important_Documents/Human_Resource_Documents/BlueCross_BlueShield_Health.pdf
More than twenty years ago, four college students asked each other: What if we could offer children from under-resourced communities individualized attention before they enter kindergarten, giving them the critical academic and social skills—the ‘jumpstart'—they need to succeed? The idea took hold and by 2015, Jumpstart had trained more than 40,000 college students and community volunteers, preparing over 87,000 children for kindergarten success. Jumpstart's program is replicated across the country in 14 states and the District of Columbia. We leverage partnerships with higher education institutions, Head Start, community-based preschools, and school districts to create sustainable solutions in order to close the kindergarten readiness gap.
Page 1 of 11 Jeff Gudin, Abel Gonzalez, Joon Lee Pain Management and Palliative Care, Englewood Hospital and Medical Center, Englewood, New Jersey, USACorrespondence to: Jeff Gudin, MD. Clinical Instructor, Anesthesiology, Icahn School of Medicine at Mount Sinai, Board Certified Pain Management, Anesthesiology, Palliative Care and Addiction Medicine; Director. Pain Management and Palliative Care, Englewood Hospital and Medical Center, 350 Engle St. Englewood, New Jersey 07631, USA. Email: [email protected]; Abel Gonzalez, MD. Department of Internal Medicine, Englewood Hospital and Medical Center, 350 Engle St, Englewood NJ 07631, USA. Email: [email protected]; Joon Lee, MD. Pain Management and Palliative Care, Englewood Hospital and Medical Center, 350 Engle St, Englewood NJ 07631, USA. Email: [email protected].
