Amendatory Rider

Riders

 

These riders modify the terms of your health plan.

Rider 12-390 Dependent Eligibility

The eligibility provisions described in your Benefit Description for dependent children have been changed.

Children of an eligible dependent child are not eligible to enroll as a dependent for coverage under the subscriber’s group membership.

All other provisions remain as described in your Benefit Description.

Rider 12-401 Dependent Eligibility

The eligibility provisions described in your Benefit Description for dependent coverage have been changed.

Coverage for eligible dependent children under the subscriber’s group membership ends on the last day of the month in which the eligible dependent child turns age 26, except when the dependent child is born on the first day of the month. In this situation, coverage will end on the eligible dependent child’s birthday.

All other provisions, including continued coverage for disabled dependent children age 26 or older, remain as described in your Benefit Description.

Rider 07-334 - Dental Services for Conditions of Cleft Lip and Cleft Palate

The inpatient and outpatient benefits described in your Benefit Description for dental services have been changed.

No benefits are provided for treatment furnished for conditions of cleft lip and cleft palate that Blue Cross and Blue Shield determines to be dental care. This includes (but is not limited to) preventive and restorative dental care, dental prosthetic management therapy, and orthodontic treatment. For these services, you must pay all charges.

All other provisions remain as described in your Benefits Description.

Rider 10-1994 Out-of-Pocket Maximum

The out-of-pocket maximum provisions as described in your Benefit Description have been changed.

Your out-of-pocket maximum is a total of copayments that you pay for inpatient admissions, outpatient day surgical admissions, and emergency room visits. You will still have to pay other copayments. The out-of-pocket maximum is $2,000 for each member in each calendar year, but no more than $4,000 for all members covered under the same health plan in each calendar year.

All other provisions remain as described in your Benefit Description.

Rider 13-328 - Prescription Drugs

The outpatient benefits described in your Benefit Description for prescription drugs and supplies purchased from a pharmacy have been eliminated.

No benefits are provided for prescription drugs and other supplies that you purchase from a retail or mail service pharmacy. For these drugs and supplies, you pay all charges.

Note: Your benefits for medical formulas have not been changed.

All other provisions remain as described in your Benefits Description.

Rider 14-006 - Routine Vision Exams

The benefits described in your Benefit Description for routine vision exams have been changed.

No benefits are provided for routine vision exams. For these services, you must pay all charges.

Note: Your benefits for medical care services and contact lenses needed to treat keratoconus and intraocular lenses implanted (or one pair of eyeglasses instead) after covered eye surgery when the natural eye lens in replaced have not been changed.

All other provisions remain as described in your Benefits Description.

Rider 15-381 - Syringes and Needles

The outpatient benefits described in your Benefit Description for syringes and needles have been changed.

No benefits are provided by this health plan for syringes and needles. For these items you must pay all costs. The only exception is when your health plan includes pharmacy benefits. In this case, pharmacy benefits are provided for disposable syringes and needles that are needed for the administration of insulin, whether or not a prescription is required.

All other provisions remain as described in your Benefits Description.

Rider 15-422 - Durable Medical Equipment

The amount you pay for durable medical equipment as described in your Benefit Description has been changed.

For these covered services, you pay 30% coinsurance for PCP/plan approved benefits or 50% coinsurance after your deductible for self-referred benefits.

All other provisions remain as described in your Benefits Description.

Rider 15-423 - Prosthetic Devices

The amount you pay for outpatient covered prosthetic devices has been changed from the amount described in your Benefit Description. For these covered services, you pay nothing.

All other provisions remain as described in your Benefit Description.

Rider 18-374 - Chiropractor Services

The copayment amount that you pay for outpatient chiropractor services has been changed from the amount described in your Benefit Description to $25 for each covered visit when the covered services are furnished by a Maine network chiropractor.

All other provisions remain as described in your Benefit Description.