Amendatory Rider

Riders

 

These riders modify the terms of your health plan.

Rider 12-003 Membership Changes

The time limit described in your Benefit Description for making membership changes has been changed.

You must request a membership change (for example, change from an individual membership to a family membership) within 72 days of the reason for the change. If you do not make the change within 72 days, you will have to wait until the group’s next open enrollment period to make the change.

All other provisions remain as described in your Benefit Description.

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 02-347 - Early Intervention Services

The outpatient benefits described in your Benefit Description for early intervention service have been changed.

Your benefits for early intervention services are limited to a maximum of $3,200 for each eligible child each calendar year, not to exceed $9,600 for the whole time the child is eligible for early intervention services.

Note: This rider does not change the age limit for early intervention services. An enrolled dependent child is eligible for early intervention services from birth through age two (until the child turns three years old).

All other provisions remain as described in your Benefits Description.

Rider 02-360 - Office Surgery

The outpatient benefits described in your Benefit Description for office or health center surgery have changed.

Any deductible, copayment, and/or coinsurance that you would normally pay for covered surgical services furnished in a network provider’s office or in a network health center no longer applies. For these covered services, you pay nothing.

All other provisions remain as described in your Benefits Description.

Rider 03-304 - Infertility Services

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

No self-referred benefits are provided for services to diagnose or treat infertility. When you chose to self-refer for these services, you must pay all charges.

All other provisions remain as described in your Benefits Description.

Rider 04-312 - Diagnostic Tests

The amount that you pay for certain covered diagnostic tests as described in your Benefit Description has been changed.

The copayment that you would normally pay for outpatient computerized axial tomography (CT scans), magnetic resonance imaging (MRI), positron emission tomography (PET scans), and nuclear cardiac imaging tests has been eliminated. For these covered services, you pay nothing.

All other provisions remain as described in your Benefits Description.

Rider 05-545 - Mental Health and Substance Abuse Treatment

The outpatient benefits described in your Benefit Description for mental health and substance abuse treatment have been changed.

The copayment amount that you would normally pay for outpatient mental health and substance abuse visits no longer applies. For these covered services, you pay nothing.

All other provisions remain as described in your Benefits Description.

Rider 06-001 - Short-term Rehabilitation Therapy

The outpatient self-referred benefits described in your Benefit Description for short-term rehabilitation therapy have been changed.

This health plan provides self-referred benefits for short-term rehabilitation therapy for as many visits as are medically necessary for your illness or injury.

Note: Your PCP/plan approved benefits for short-term rehabilitation therapy have not been changed by this rider.

All other provisions remain as described in your Benefits 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 10-2131 - Copayments

The copayment amount for certain outpatient covered services has been changed from the amount described in your Benefit Description to:

1. $15 copayment for each visit for the following covered services:

  • cardiac rehabilitation services;
  • medical care services to diagnose or treat your illness, condition or injury, when the covered service is furnished by your primary care provider or by a network obstetrician, network gynecologist, network nurse practitioner, network nurse midwife or network physician assistant;
  • medical care services for treatment of infertility
  • mental health and/or substance abuse treatment; and
  • speech/language therapy

2. $20 copayment for each visit for the following covered services:

  • medical care services to diagnose or treat your illness, condition, or injury, when the covered service is furnished by a network specialist, including (but not limited to) a network chiropractor or a network podiatrist; and
  • physical and occupational therapy.

Refer to Schedule of Benefits section above for a description of the covered services for which the lower and higher copayments apply.

Note: This rider does not change the amount you must pay for emergency room visits; diagnostic tests (such as lab tests and imaging tests); prescription drugs; and outpatient day surgery).

All other provisions remain as described in your Benefits Description.

Rider 10-671 - Deductible

The deductible amount described in your Benefit Description has been changed to $300 for each member, but no more than $600 for all family members under the same membership, in each calendar year. Refer to the Schedule of Benefits section above for a description of the covered services for which the deductible applies.

All other provisions remain as described in your Benefits 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 14-475 - Hearing Aids

The outpatient benefits described in your Benefit Description for routine hearing care have been changed.

This health plan provides benefits for one hearing aid for up to $2,000 (or up to $2,000 for one set of binaural hearing aids) for each member once every 36 months. This includes dispensing fees, acquisition costs, batteries and the repair of the hearing aids. You pay nothing until this benefit limit has been reached. Then, you must pay all charges that are in excess of this amount for that eligible time period. (Any deductible, coinsurance or copayment described in your Benefit Description does not apply to this hearing aid benefit).

At the time of your visit to purchase hearing aids, the provider may ask you to pay all billed charges. In this case, you will have to file a claim to Blue Cross and Blue Shield for repayment of these covered services. To file a claim for repayment, you must: fill out a claim form; attach your original itemized bills; and mail the claim to the Blue Cross and Blue Shield customer service office. You can obtain claim forms from the Blue Cross and Blue Shield customer service office.

No benefits are provided for hearing aids delivered more than 60 days after your termination date under this health plan (even if they were prescribed while you were covered under this health plan); replacement parts for the hearing aids; and charges to replace lost or broken hearing aids (unless at the time you replace them you have gone more than 36 months in a row without receiving these benefits and your condition requires that you receive new hearing aids).

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 to: no cost for PCP/plan Approved benefits for 20% coinsurance for Self-Referred benefits.

All other provisions remain as described in your Benefits Description.

Rider 18-308 - Chiropractor Services

The outpatient benefits described in your Benefit Description for covered services furnished by a chiropractor have been changed.

Your benefits for outpatient chiropractic services furnished by a chiropractor are limited to 20 visits each calendar year for each member (regardless of age). Once you reach this benefit limit, no more benefits will be provided for chiropractor services during the rest of that year, whether or not these chiropractic services are medically necessary for you.

All other provisions remain as described in your Benefits Description.

Rider WT$300 - Weight Loss Programs

The benefits described in your Benefit Description for wellness programs have been changed. The weight loss program benefit has been increased to $300 for each membership for each calendar year.

All other provisions remain as described in your Benefits Description.