Summary of BCBS Coverage
| Benefits | Blue Cross coverage for LTD Employee without Medicare A & B |
Blue Cross Coverage for LTD Employee with Medicare A & B |
| Hospitalization Inpatient/Outpatient | Pays 90% of any reasonable charge after deductible has been met. | Pays Medicare’s inpatient deductible coinsurance, extends inpatient days to 365.
Pays Annual Part B deductible/coinsurance |
| Skilled Nursing Facility | Not Covered | Pays Medicare daily coinsurance for 21st - 100th day. |
| Surgery, Technical Surgical Assistance, Anesthesia, Medical Care, Laboratory, X-ray | Pays 90% of any reasonable charge after deductible has been met. | Pays Medicare deductible/coinsurance |
| Mental Health Treatment | Inpatient – Pays 90% of reasonable charge after deductible has been met up to 45 days per calendar year.
Outpatient -- Pays 50% of reasonable charge after deductible has been met, up to 20 visits per year. |
Pays Medicare deductible/coinsurance
Pays Medicare deductible/coinsurance |
| Emergency Services (First aid/Medical Emergencies) | Pays 90% of any reasonable charge after deductible has been met for accidental or life threatening medical emergencies. | Pays Medicare deductible/coinsurance |
| Substance Abuse Inpatient Treatment | Pays 90% of any reasonable charge after deductible has been met, up to 45 days per calendar year. | Pays Medicare deductible/coinsurance |
| Annual Deductible | $100 per person, $500 per family | $0.00 |
| Co-Payment | 10% | $0.00 |
| Stop Loss | $500 per person per year, $1,000 per family per year | $0.00 |
| Office visits | Pays 90% of any reasonable charges after deductible has been met. | Not covered |
| Allergy Testing/Therapy | Pays 90% of any reasonable charge after deductible has been met. | Not covered |
| Physical Therapy | Pays 90% of any reasonable charge after deductible has been met for 60 days from first date of treatment in an approved facility when prescribed by a doctor and designed to restore function to specific part of body. | Pays Medicare deductible/coinsurance when services rendered in a Blue Cross approved facility-not covered in doctor’s office. |
| Durable Medical Equipment (i.e., wheelchair, walker, etc.) | With doctor’s prescription pays 90% of any reasonable charge after deductible has been met. | Pays Medicare deductible/coinsurance |
| Medical Supplies (i.e., splints, casts, colostomy bags) | Pays 90% of any reasonable charge after deductible has been met. | Pays Medicare deductible/coinsurance |
| *Prescription Drugs | $10.00 co-pay for 34-day supply | $10.00 co-pay for 34-day supply |
*Please note the Prescription Drug Program is a PPO arrangement. Member pays only the co-payment when prescription is filled at a network pharmacy. If a non-network pharmacy is used, member is responsible for 25% of approved charges in addition to co-payment. Program also includes generic drug program called Maximum Allowable Cost requiring generic drug be dispensed (when available) unless doctor indicates "Dispense As Written" (DAW) on prescription.
Medicare and Complementary Coverage Exclusions
The following services are excluded under both Medicare and your Complementary Coverage:
- Routine physical examinations
- Routine foot care
- First three pints of blood
- Eyeglasses and routine eye examinations
- Hearing aids and examinations
- Dentures or routine care and treatment of teeth
- Orthopedic shoes
- Jobst stockings
- Cosmetic surgery
- Custodial care