Teamsters Local 170 Health and Welfare Fund

Blue Choice New England Plan 2

Schedule of Benefits

 

This is the Schedule of Benefits that is a part of your Benefit Description. This chart describes the cost share amounts that you must pay for covered services. It also shows the benefit limits that apply for covered services. Do not rely on this chart alone. Be sure to read all parts of your Benefit Description to understand the requirements that you must follow to receive all of your coverage. You should also read the descriptions of covered services and the limitations and exclusions that apply for this coverage. These provisions are fully described in your Benefit Description. You will receive the highest benefit level when you obtain covered services from your primary care provider or, when they are arranged or recommended by your PCP, from other covered providers who participate in teh HMO Blue New England health care network. (The service are where your covered services will be furnished includes all counties in Massachusetts, Connecticut, Maine, New Hampshire, Rhode Island, and Vermont.) These benefits are your “PCP/Plan Approved Benefits.” When you self refer for covered services or obtain covered services from a covered provider who does not participate in your health care network, you will usually receive a lower benefit level. These benefits are your “Self-Referred Benefits.” Also, when it is required, you must receive an approval from Blue Cross and Blue Shield as outlined in your Benefit Description (see Part 4). You should make sure that you have received the approval from Blue Cross and Blue Shield before you receive the covered services. Otherwise you may have to pay all costs.

IMPORTANT NOTE: Blue Cross and Blue Shield and/or your group may change the provisions described in this Schedule of Benefits. If this is the case, the change is described in a rider. Be sure to read each rider (if there is any) that applies to your coverage in this health plan to see if it changes this Schedule of Benefits.

Overall Member Cost Share Provisions PCP/Plan Approved Benefits Self-Referred Benefits
Deductible
Your deductible per Calendar Year:

This deductible applies to all self-referred benefits except for certain covered services as noted in this chart.

$0 $250 per member

$500 per family

The family deductible can be met by eligible costs incurred by any combination of members enrolled under the same family plan. But, no one member will have to pay more than the per member deductible.
 
Out-of-Pocket Maximum
Your out-of-pocket maximum per Calendar Year:

This out-of-pocket maximum is a total of your deductible and coinsurance, only for self-referred benefits. You will still have to pay any costs not included in this out-of-pocket maximum.

None $1,000 per member

$2,000 per family

The family out-of-pocket maximum can be met by eligible costs incurred by any combination of members enrolled under the same family plan. But, no one member will have to pay more than the per member out-of-pocket maximum.
 
Overall Benefit Maximum None None

 

Covered Services PCP/Plan Approved Benefits
Your Cost Is:
Self-Referred Benefits
Your Cost Is:
Admissions for Inpatient Medical and Surgical Care
In a General Hospital No charge 20% coinsurance after deductible
In a Chronic Disease Hospital No charge 20% coinsurance after deductible
In a Rehabilitation Hospital

(60-day benefit limit per member per calendar year)

No charge up to benefit limit; then, you pay all costs 20% coinsurance after deductible up to benefit limit; then, you pay all costs
In a Skilled Nursing Facility (100-day benefit limit per member per calendar year) No charge up to benefit limit; then, you pay all costs 20% coinsurance after deductible up to benefit limit; then, you pay all costs
 
Ambulance Services
(ground or air ambulance transport)
Emergency Ambulance No Charge No charge (deductible does not apply)
Other Ambulance No Charge No charge (deductible does not apply)
 
Cardiac Rehabilitation
Outpatient Services $10 copayment per visit 20% coinsurance after deductible
 
Chiropractor Services
(for members of any age)
Outpatient lab tests and x-rays See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests
Outpatient medical care services, including spinal manipulation $10 copayment per visit 20% coinsurance after deductible
 
Dialysis Services
Outpatient services and home dialysis No charge 20% coinsurance after deductible
 
Durable Medical Equipment
Covered medical equipment rented or purchased for home use 20% coinsurance 20% coinsurance after deductible
One breast pump per birth (rented or purchased) No charge 20% coinsurance after deductible
No coverage is provided for hospital-grade breast pumps.
 
Early Intervention Services
(for an eligible child through age two) No charge No charge (deductible does not apply)
 
Emergency Medical Outpatient Services
Emergency room services $100 copayment per visit $100 copayment per visit
(deductible does not apply)
The emergency room copayment is waived if the visit results in your being held for an overnight observation stay or being admitted for inpatient care within 24 hours.
Primary Care Provider, OB/GYN physician, physician assistant, nurse practitioner, and nurse midwife services $10 copayment per office* visit or home visit 20% coinsurance after deductible
Other covered provider services (non-hospital) $10 copayment per office* or home visit 20% coinsurance after deductible
Hospital services* (outpatient visit) No charge 20% coinsurance after deductible
 
Home Health Care
Home care program No charge 20% coinsurance after deductible
 
Hospice Services
Inpatient or outpatient hospice services for terminally ill No charge 20% coinsurance after deductible
 
Infertility Services
Inpatient services See Admissions for Inpatient Medical and Surgical Care See Admissions for Inpatient Medical and Surgical Care
Outpatient surgical services See Surgery as an Outpatient See Surgery as an Outpatient
Outpatient lab tests and x-rays See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests
Outpatient medical care services See Medical Care Outpatient Visits See Medical Care Outpatient Visits
 
Lab Tests, X-Rays, and Other Tests
Outpatient Lab Tests No charge 20% coinsurance after deductible
Outpatient x-rays No charge 20% coinsurance after deductible
Outpatient CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (copayment does not apply to interpretation costs) $25 copayment per category of test per service date 20% coinsurance after deductible
When copayments for these advanced imaging tests add up to a total of $375 per member in a calendar year, you pay nothing for these covered tests for the balance of the calendar year.
Other outpatient tests and preoperative tests No Charge 20% coinsurance after deductible
 
Maternity Services and Well Newborn Inpatient Care (includes $90/$45 for childbirth classes; deductible does not apply)
Maternity services (includes delivery and postnatal care) No Charge 20% coinsurance after deductible
Prenatal Care No Charge 20% coinsurance after deductible
Well newborn care during enrolled mother’s maternity admission No Charge 20% coinsurance (deductible does not apply)
 
Medical Care Outpatient Visits (includes syringes and needles dispensed during a visit)
Primary care provider, OB/GYN physician, physician assistant, nurse practitioner, and nurse midwife services $10 copayment per office or home visit 20% coinsurance after deductible
Other covered provider services (non-hospital) $10 copayment per office or home visit 20% coinsurance after deductible
Hospital services (outpatient visit) No charge 20% coinsurance after deductible
 
Medical Formulas (includes certain medical formulas and low protein foods)
$5,000 benefit limit per member per calendar year for low protein foods No charge for covered services; otherwise you pay all costs 20% coinsurance after deductible for covered services; otherwise you pay all costs
 
Mental Health and Substance Abuse Treatment
Refer to your Benefit Description for more information
Inpatient admissions in a General Hospital No charge 20% coinsurance after deductible
Inpatient admissions in a Mental Hospital or Substance Abuse Facility No charge 20% coinsurance after deductible
Outpatient Services $10 copayment per visit; or no charge for hospital services 20% coinsurance after deductible
 
Oxygen and Respiratory Therapy
Oxygen and Equipment for its administration No charge 20% coinsurance after deductible
Outpatient respiratory therapy No charge 20% coinsurance after deductible
 
Podiatry Care
Outpatient lab tests and x-rays See Lab Tests, X-Rays and Other Tests See Lab Tests, X-Rays and Other Tests
Outpatient surgical services See Surgery as an Outpatient See Surgery as an Outpatient
Outpatient medical services See Medical Care Outpatient Visits See Medical Care Outpatient Visits
 
Prescription Drugs and Supplies
Drug formulary (includes syringes and needles)
For insulin infusion pumps, you pay nothing
Retail Pharmacy (up to 30-day supply) Tier 1: $10 copayment
Tier 2: $25 copayment
Tier 3: $45 copayment
Not covered; you pay all costs
Full PCP/plan approved benefits are provided for Tier 1 birth control drugs and devices. For these covered services, you pay nothing.
Mail Service Pharmacy (up to 90 day supply) Tier 1: $20 copayment
Tier 2: $50 copayment
Tier 3: $90 copayment
Not covered; you pay all costs
Full PCP/plan approved benefits are provided for Tier 1 birth control drugs and devices. For these covered services, you pay nothing.
 
Preventive Health Care Services
Includes: $150 Fitness Benefit
$150 Weight Loss Program Benefit
Refer to your Benefit Description for a complete description of covered services
Routine pediatric care No charge 20% coinsurance after deductible
These covered services include (but are not limited to): routine exams; immunizations; routine lab tests and x-rays; and blood tests to screen for lead poisoning.
Preventive dental care No charge for a member under age 18 for treatment of cleft lip and cleft palate; otherwise, you pay all costs. 20% coinsurance after deductible for a member under age 18 for treatment of cleft lip and cleft palate; otherwise, you pay all costs.
Routine adult exams and tests No charge 20% coinsurance after deductible
These covered services include (but are not limited to): routine exams; immunizations; routine lab tests and x-rays; routine mammograms at least once between age 35 through 39 and once per calendar year for age 40 or older; blood tests to screen for lead poisoning; and routine colonoscopies.
Routine GYN exams (once per member per calendar year) No charge for covered services; otherwise, you pay all costs 20% coinsurance after deductible for covered services; otherwise you pay all costs
These covered services include a routine Pap smear test once per member per calendar year.
Family planning No charge 20% coinsurance after deductible
Routine hearing care services Routine Hearing Exams/Tests: No charge
Hearing Aids: Not covered; you pay all costs
Routine Hearing Exams/Tests: 20% coinsurance after deductible
Hearing Aids: Not covered; you pay all costs
These covered services include newborn hearing screening tests
Routine vision exams (one exam per member every 24 months) No charge for covered exams; otherwise, you pay all costs 20% coinsurance after deductible for covered exams; otherwise you pay all costs
 
Prosthetic Devices
Ostomy supplies No charge 20% coinsurance after deductible
Artificial limb devices (includes repairs) and other external prosthetics devices 20% coinsurance 20% coinsurance after deductible
 
Radiation Therapy and Chemotherapy
Outpatient services No charge 20% coinsurance after deductible
 
Second Opinions
Outpatient second and third surgical opinions See Medical Care Outpatient Visits See Medical Care Outpatient Visits
 
Short-term Rehabilitation Therapy
Outpatient physical, occupational, and speech therapy (60-visit benefit limit per member per calendar year) $10 copayment per visit for covered services; otherwise you pay all costs 20% coinsurance after deductible for covered services; otherwise you pay all costs
This benefit limit does not apply for: speech therapy; and when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care.
 
Speech, Hearing and Language Disorder Treatment
Outpatient diagnostic tests See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests
Outpatient speech therapy See Short-Term Rehabilitation Therapy See Short-Term Rehabilitation Therapy
Outpatient medical care services See Medical Care Outpatient Visits See Medical Care Outpatient Visits
 
Surgery as an Outpatient
(includes removal of impacted teeth that are fully or partially imbedded in the bone)
Surgical day care unit of hospital, ambulatory surgical facility, and hospital surgery services No charge 20% coinsurance after deductible
Sterilization procedure for a female member when performed as the primary procedure for family planning reasons No charge 20% coinsurance after deductible
Primary care provider, OB/GYN physician, physician assistant, nurse practitioner, and nurse midwife services $10 copayment per office visit 20% coinsurance after deductible
Other covered provider services (non-hospital) $10 copayment per office visit 20% coinsurance after deductible
 
TMJ Disorder Treatment
Outpatient x-rays See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests
Outpatient surgical services See Surgery as an Outpatient See Surgery as an Outpatient
Outpatient physical therapy (short-term rehabilitation therapy benfit limit applies) See Short-Term Rehabilitation Therapy See Short-Term Rehabilitation Therapy
Outpatient medical care services See Medical Care Outpatient Visits See Medical Care Outpatient Visits