Amendatory Rider

Amendatory Rider

 

This rider modifies the terms of your health plan. Please keep this rider with your Benefit Description for easy reference.

Rider 08-337 - Allowed Charge

The amount that Blue Cross and Blue Shield uses to calculate your benefits for covered services furnished by non-preferred providers has been changed.

The term “Allowed Charge” as described in Part 2 of your Benefit Description has been changed by replacing the third bullet with the following provision:

For Other Health Care Providers. For covered providers in Massachusetts who do not have a PPO payment agreement with Blue Cross and Blue Shield and for all covered health care providers outside of Massachusetts who do not have a payment agreement with the local Blue Cross and/or Blue Shield Plan, Blue Cross and Blue Shield uses the health care provider’s actual charge to calculate your claim payment. For covered services furnished by these covered providers, you pay only your deductible and/or your copayment and/or your coinsurance, whichever applies.

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.

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 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 07-004 - Oral Surgery

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

Your benefits for oral surgical services also include:

  • Surgical removal of impacted or unerupted teeth when imbedded in the bone.
  • Extraction of seven or more permanent teeth.
  • Gingivectomies involving two or more gum quadrants (each quadrant must consist of a minimum of five and a maximum of eight teeth).

These benefits are provided only when you have a serious medical condition that requires that you be admitted to a hospital as an inpatient or to a surgical day care unit of a hospital or to an ambulatory surgical facility in order for the surgery to be safely performed.

No benefits are provided for these services when furnished in a provider’s office.

All other provisions 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 Benefit Description.

Rider 13-564 - Prescription Drugs

The outpatient benefits described in your Benefit Description for prescription drugs and supplies have changed.

No benefits are provided for prescription drugs and other supplies that you purchase from a retail or mail service pharmacy. For these drugs and most supplies, you must pay all charges. There are some exceptions. This health plan will continue to provide benefits for special medical formulas, enteral formulas and low protein food products as described in your Benefit Description. Any copayment, deductible and/or coinsurance that you would normally pay for these covered services has been waived. For these covered services, you pay nothing.

All other provisions remain as described in your Benefit Description.

Rider 14-405 - Preventive Health Services

The outpatient benefits for certain preventive health services as described in your Benefit Description have been changed.

Your coverage for routine colonoscopies and routine sigmoidoscopies (or barium enemas) is provided only for a member who is age 50 or older, once every ten calendar years for a routine colonoscopy and once every three calendar years for a routine sigmoidoscopy or barium enema.

All other provisions remain as described in your Benefit 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 Benefit 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 Benefit 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 Benefit Description.