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MEDICAL BENEFIT BOOKLET
For
GXO
HSA Basic
Administered By
Si usted necesita ayuda en español para entender este document, puede solicitalia gratuitamente llamando a Servicios al Cliente al número que se encuentra en su tarjeta de identificación If You need assistance in Spanish to understand this document, You may request it for free by calling Member Services at the number on Your Identification Card 2
This Benefit Booklet provides You with a description of Your benefits while You are enrolled under the health care plan (the Plan) offered by Your Employer. You should read this booklet carefully to familiarize yourself with the Plan’s main provisions and keep it handy for reference. A thorough understanding of Your coverage will enable You to use Your benefits wisely. If You have any questions about the benefits as presented in this Benefit Booklet, please contact Your Employer’s Group Health Plan Administrator or call the Claims Administrator’s Member Services Department.
The Plan provides the benefits described in this Benefit Booklet only for eligible Members. The health care services are subject to the Limitations and Exclusions, Copayments, Deductible, and Coinsurance requirements specified in this Benefit Booklet. Any group plan or certificate which You received previously will be replaced by this Benefit Booklet.
Your Employer has agreed to be subject to the terms and conditions of Anthem’s Provider agreements which may include precertification and utilization management requirements, timely filing limits, and other requirements to administer the benefits under this Plan. This is a Preferred Provider Organization (PPO) Plan for all Members except residents of Florida, Georgia, Missouri, District of Columbia/Maryland, New Hampshire, New York, New Jersey and Wisconsin; Members residing in those states are part of a Point of Service (POS) Plan, and must use the appropriate POS Network Provider in their respective states to receive Network benefits. If You are a Member in a state outside of Florida Georgia, Missouri, District of Columbia/Maryland, New Hampshire, New York, New Jersey and Wisconsin that participates in an Select Network arrangement, please call the Member Services number on Your Identification Card to locate participating Providers. Anthem Blue Cross and Blue Shield, or “Anthem” has been designated by Your Employer to provide administrative services for the Employer’s Group Health Plan, such as claims processing, care management, and other services, and to arrange for a network of health care Providers whose services are covered by the Plan. Important: This is not an insured benefit Plan. The benefits described in this Benefit Booklet or any rider or amendments attached hereto are funded by the Employer who is responsible for their payment. Anthem provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims.
Anthem is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, permitting Anthem to use the Blue Cross and Blue Shield Service Marks in portions of the state of Connecticut, You will have access to Providers participating in the Blue Cross and Blue Shield Association BlueCard® PPO network across the country. Anthem has entered into a contract with the Employer on its own behalf and not as the agent of the Association.
Verification of Benefits
Verification of benefits is available for Members or authorized healthcare Providers on behalf of Members. You may call Member Services with a benefits inquiry or verification of benefits during normal business hours (8:00 a.m. to 8:00 p.m. eastern time). Please remember that a benefits inquiry or verification of benefits is NOT a verification of coverage of a specific medical procedure. Verification of benefits is NOT a guarantee of payment. CALL THE MEMBER SERVICES NUMBER ON YOUR IDENTIFICATION CARD or see the section titled Health Care Management – Precertification rules.
Identity Protection Services
Identity protection services are available with Your Employer’s Anthem health plans. To learn more about these services, please visit www.anthem.com/resources.
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MEMBER RIGHTS AND RESPONSIBILITIES 4 SCHEDULE OF BENEFITS 6 TOTAL HEALTH AND WELLNESS SOLUTION 19 ELIGIBILITY 22 HOW YOUR PLAN WORKS 25 HEALTH CARE MANAGEMENT – PRECERTIFICATION 27 BENEFITS 36 LIMITATIONS AND EXCLUSIONS 49 CLAIMS PAYMENT 52 YOUR RIGHT TO APPEAL 60 COORDINATION OF BENEFITS (COB) 64 SUBROGATION AND REIMBURSEMENT 69 GENERAL INFORMATION 71 WHEN COVERAGE TERMINATES 76 DEFINITIONS 80 HEALTH BENEFITS COVERAGE UNDER FEDERAL LAW 91 IT’S IMPORTANT WE TREAT YOU FAIRLY 94 GET HELP IN YOUR LANGUAGE 95 4
MEMBER RIGHTS AND RESPONSIBILITIES
As a Member You have rights and responsibilities when receiving health care. As Your health care partner, the Claims Administrator wants to make sure Your rights are respected while providing Your health benefits. That means giving You access to the Claims Administrator’s network of health care Providers and the information You need to make the best decisions for Your health. As a Member, You should also take an active role in Your care. You have the right to:
• Speak freely and privately with Your health care Providers about all health care options and treatment needed for Your condition no matter what the cost or whether it is covered under Your Plan.
• Work with Your Doctors to make choices about Your health care.
• Be treated with respect and dignity.
• Expect the Claims Administrator to keep Your personal health information private by following the Claims Administrator’s privacy policies, and state and Federal laws.
• Get the information You need to help make sure You get the most from Your health Plan, and share Your feedback. This includes information on”
− The Claims Administrator’s company and services.
− The Claims Administrator network of health care Providers.
− Your rights and responsibilities.
− The rules of Your health Plan.
− The way Your health Plan works.
• Make a complaint or file an appeal about:
− Your health Plan and any care You receive.
− Any Covered Service or benefit decision that Your health Plan makes.
• Say no to care, for any condition, sickness or disease, without having an effect on any care You may get in the future. This includes asking Your Doctor to tell You how that may affect Your health now and in the future.
• Get the most up-to-date information from a health care Provider about the cause of Your illness. Your treatment and what may result from it. You can ask for help if You do not understand this information. You have the responsibility to:
• Read all information about Your health benefits and ask for help if You have questions.
• Follow all health Plan rules and policies.
• Choose a Network Primary Care Physician, also called a PCP, if Your health Plan requires it.
• Treat all Doctors, health care Providers and staff with respect.
• Keep all scheduled appointments. Call Your health care Provider’s office if You may be late or need to cancel.
• Understand Your health problems as well as You can and work with Your health care Providers to make a treatment plan that You all agree on.
• Inform Your health care Providers if You don’t understand any type of care You’re getting or what they want You to do as part of Your care plan.
• Follow the health care plan that You have agreed on with Your health care Providers.
• Give the Claims Administrator, Your Doctors and other health care Providers the information needed to help You get the best possible care and all the benefits You are eligible for under Your health Plan. This may include information about other health insurance benefits You have along with Your coverage with the Plan.
• Inform Member Services if You have any changes to Your name, address or family members covered under Your Plan.
If You would like more information, have comments, or would like to contact the Claims Administrator, please go to anthem.com and select Customer Support > Contact Us. Or call the Member Services number on Your Identification Card.
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The Claims Administrator wants to provide high quality customer service to our Members. Benefits and coverage for services given under the Plan are governed by the Employer’s Plan and not by this Member Rights and Responsibilities statement.
How to Obtain Language Assistance
Anthem is committed to communicating with our Members about their health plan regardless of their language. Anthem employs a language line interpretation service for use by all of our Member Services Call Centers. Simply call the Member Services phone number on the back of Your Identification Card and a representative will be able to assist You. TTY/TDD service also are available by dialing 711. A special operator will get in touch with us to help with Your needs.
6
SCHEDULE OF BENEFITS
The Maximum Allowed Amount is the amount the Claims Administrator will reimburse for services and supplies which meet its definition of Covered Services, as long as such services and supplies are not excluded under the Member’s Plan. See the Definitions and Claims Payment sections for more information. Under certain circumstances, if the Claims Administrator pays the healthcare Provider amounts that are Your responsibility, such as Deductibles, Copayments or Coinsurance, the Claims Administrator may collect such amounts directly from You. You agree that the Claims Administrator has the right to collect such amounts from You. Welcome to the Health Savings Account (HSA) Plan!
With the HSA plans, You have health coverage available to You for which You and the company share the cost. This coverage has two components designed to work together to provide You flexibility and control in choosing the health care services You and Your family members receive and in choosing how the cost of these services is paid. Bottom line, the plans are designed to help You – and Your family – take control of Your health care dollars and decisions.
How the HSA Plan Works
The HSA Plan is an innovative approach to health benefits that puts You in charge of the money You spend for health care services and helps You get the most out of Your company-sponsored health coverage. With the HSA Plan, You have flexibility and control in choosing the health care services You and Your family members receive – and in determining how the cost of these services is paid. The HSA Plan – In Brief
First – Using Your HSA to pay for Covered Services: Health Savings Account
With the Health Savings Account (HSA), You can contribute pre-tax dollars to Your HSA. Others may also contribute dollars to Your account. You can use the dollars to help meet Your annual Deductible responsibility. Unused dollars can be saved or invested and accumulate through retirement. Plus – To help You stay healthy, use:
Preventive Services
100% coverage for nationally recommended services using Network Providers. No deductions from the HSA or Out-of-Pocket costs for You as long as You receive Your preventive care from a Network Provider. If You choose to go to an Out-of-Network Provider, Your Deductible or Traditional Health Coverage benefits will apply.
If needed:
Traditional Health Coverage
Traditional Health Coverage is made available by Your Employer on a self-funded basis and helps to protect You and Your family in case You have significant health care expenses. Coverage is effective once You have met an up-front Out-of-Pocket cost for covered expenses (Your Deductible). Once coverage is effective, the Plan will reimburse a percentage of the cost for Covered Services. You will be responsible for covering the remainder of the expense of Covered Services, up to an annual Out-of-Pocket Maximum. After this amount has been met, You will receive coverage for Covered Services for the remainder of the Plan year as specified elsewhere in this Benefit Booklet. The Traditional Health coverage is governed by the details contained elsewhere in this document. NOTE: Words and phrases within this document that are denoted with initial capitalization have the meaning ascribed to them within the document itself, or within the Definitions section. The company reserves the right to amend or terminate the Plan at any time. You will be notified of any changes that affect Your benefits, as required by Federal law. 7
Financial Tools
Each Plan offers online financial tools to help You keep track of Your health care dollars. Plus You can track Your claims for Covered Services. You can review what You have spent on health care, view Your balance, or look up the status of a particular claim any time of the day. To receive maximum benefits at the lowest Out-Of-Pocket expense, Covered Services must be provided by a Network Provider. Benefits for Covered Services are bases on the Maximum Allowed Amount, which is the maximum amount the Plan will pay for a given service. When you use an Out-of-Network Provider, You are responsible for any balance due between the Out-of-Network Provider’s charge and the Maximum Allowed Amount in addition to any Coinsurance, Deductibles and non-covered changes. Coinsurance/Maximums are calculated based upon the maximum Allowed Amount, not the Provider’s charge. Contributions to your HSA
For 2021, contributions can be made to Your HSA up to the following: Contributions to Your HSA
Individual Coverage $3,600
Family Coverage $7,200
Note: These limits apply to all combined contributions from any source, except rollover funds. Your Deductible is:
Deductible Network Out-of-Network
Individual Coverage $2,500 $5,000
Family Coverage $5,000 $10,000
Note: The Deductible applies to all Covered Services with Coinsurance amounts You incur in a Benefit Period except for the following:
• Network Preventive Services
Your Plan has a non-embedded Deductible which means:
• If You, the Subscriber, are the only person covered by this Plan, only the “Individual” amounts apply to You.
• If You, also cover Dependents (other family members) under this Plan, only the “Family” amounts apply. The
“Family” Deductible amounts can be satisfied by a family member or a combination of family members. Once the Family Deductible is met, it is considered met for all family members. Traditional Health Coverage
The Plan pays:
Coinsurance
Traditional Health Coverage
Coinsurance
Network Out-of-Network
The Plan Pays 70% 50%
Your Coinsurance Responsibility 30% 50%
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Out-of-Pocket Maximum
The Plan’s Out-of-Pocket Maximum is the most that You will pay toward covered health expenses in a Plan year. Once You reach the Out-of-Pocket Maximum under the Plan, the Plan pays 100% of Covered Services for Providers who offer discounts and 100% of the Maximum Allowed Amount for Providers who do not offer discounts. Your Out-of-Pocket Maximum is:
Out-of-Pocket Maximum Network Out-of-Network
Individual Coverage $5,000 $10,000
Individual on Family Contract $7,150 $20,000
Family Coverage $10,000 $20,000
Your Plan has an embedded Out-of-Pocket which means:
• If You, the Subscriber, are the only person covered by this Plan, only the “Individual” amounts apply to You.
• If You, also cover Dependents (other family members) under this Plan, both the “Individual” and “Family” amounts apply. The “Family” Out-of-Pocket amounts can be satisfied by any combination of family members but You could satisfy Your own “Individual” Out-of-Pocket amount before the “Family” amount is met. You will never have to satisfy more than Your own “Individual” Out-of-Pocket amount. If You meet Your “Individual” amount, other family member’s claims will still accumulate towards their own “individual” Out-of-Pocket and the overall “Family” amounts. This continues until Your other family members meet their own “Individual” Out-of- Pocket or the entire “Family” Out-of-Pocket is met. Note: The Out-of-Pocket Maximum includes all Deductible and/or Coinsurance You incur in a Benefit Period. Once the Out-of-Pocket Limit is satisfied, no additional Coinsurance will be required for the remainder of the Benefit Period.
Schedule of Benefits Network Out-of-Network
Calendar Year Deductible
Individual $2,500 $5,000
Family $5,000 $10,000
Copayments and charges in excess of the Maximum Allowed Amount do not contribute to the Deductible. All Covered Services are subject to the Deductible unless otherwise specified in this booklet. Your Plan has a non-embedded Deductible which means:
• If You, the Subscriber, are the only person covered by this Plan, only the “Individual” amounts apply to You.
• If You also cover Dependents (other family members) under this Plan, only the “Family” amounts apply. The “Family” Deductible amounts can be satisfied by a family member or a combination of family members. Once the Family Deductible is met, it is considered met for all family members. Amounts satisfied toward the Network calendar year Deductible will be applied toward the Out-of-Network calendar year Deductible and amounts satisfied toward the Out-of-Network calendar year Deductible will be applied toward the Network calendar year Deductible. 9
Schedule of Benefits Network Out-of-Network
Coinsurance After the Calendar Year Deductible is
Met (Unless Otherwise Specified)
Plan Pays 70% 50%
Member Pays 30% 50%
All payments are based on the Maximum Allowed Amount and any negotiated arrangements. For Out-of- Network Providers, You are responsible to pay the difference between the Maximum Allowed Amount and the amount the Provider charges. Depending on the service, this difference can be substantial. Out-of-Pocket
Includes Coinsurance and the calendar year Deductible. Does NOT include precertification penalties, charges in excess of the Maximum Allowed Amount or Non-Covered Services. Individual
Individual on Family Contract
$5,000
$7,150
$10,000
$20,000
Family $10,000 $20,000
Your Plan has an embedded Out-of-Pocket which means:
• If You, the Subscriber, are the only person covered by this Plan, only the “Individual” amounts apply to You.
• If You also cover Dependents (other family members) under this Plan, both the “Individual” and
“Family” amounts apply. The “Family” Out-of-Pocket amounts can be satisfied by any combination of family members but You could satisfy Your own “Individual” Out-of-Pocket amount before the
“Family” amount is met. You will never have to satisfy more than Your own “Individual” Out-of- Pocket amount. If You meet Your “Individual” amount, other family member’s claims will still accumulate towards their own “Individual” Out-of-Pocket and the overall “Family” amounts. This continues until Your other family members meet their own “Individual” Out-of-Pocket or the entire
“Family” Out-of-Pocket is met.
Amounts satisfied toward the Network Out-of-Pocket Maximum will be applied toward the Out-of-Network Out-of-Pocket Maximum and amounts satisfied toward the Out-of-Network Out-of-Pocket Maximum will be applied toward the Network Out-of-Pocket Maximum.
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Benefits
Member Responsibility
Network Out-of-Network
Note: All Covered Services are subject to the Deductible and applicable Coinsurance unless otherwise specified in this booklet
Acupuncture 30% 50%
Maximum Days 25 Days Maximum Per Calendar Year
Combined In and Out-of-Network
Allergy Care
Testing 30% 50%
Treatment 30% 50%
Behavioral Health/Substance Abuse Care
Hospital Inpatient Services 30% 50%
Outpatient Services 30% 50%
Physician Services (Home and Office Visits-Including Online Visits
Note: Online Visits Out-of-Network and, non-
LiveHealth Online Providers are Not Covered.
30% 50%
Applied Behavioral Analysis (ABA) Therapy 30% 50%
Note: Coverage for the treatment of Behavioral Health and Substance Abuse Care conditions is provided in compliance with Federal law.
Clinical Trials
See Clinical Trials under Benefits section for further information.
Benefits are paid based
on the setting in which
Covered Services are
received
Benefits are paid based
on the setting in which
Covered Services are
received
Dental & Oral Surgery/TMJ Services
Accidental Injury to Natural Teeth (Treatment must be completed within 6 months of the Injury)
30%
30%
50%
Oral Surgery/TMJ - Subject to Medical Necessity – 50% excludes appliances and orthodontic treatment
11
Benefits
Member Responsibility
Network Out-of-Network
Note: All Covered Services are subject to the Deductible and applicable Coinsurance unless otherwise specified in this booklet
Diagnostic Physician’s Services
Diagnostic services (including second opinion) by a Physician or Specialist Physician – office visit or home visit:
Primary Care Physician 30% 50%
Specialist Physician 30% 50%
Diagnostic X-ray and Lab – office or independent lab 30% 50% Note: Diagnostic services are defined as any claim for services performed to diagnose an illness or Injury.
Emergency Room, Urgent Care, and Ambulance
Services
Emergency Room for an Emergency Medical Condition
All other services
30%
30%
30%
30%
(See note below)
Use of the Emergency Room for Non-Emergency
Medical Conditions
Emergency room visit (per visit) Coinsurance
All other services
30%
30%
30%
30%
Urgent Care Clinic Visit for an Emergency Medical
Condition
Clinic visit (per visit) Coinsurance
All other services
30%
30%
50%
50%
Ambulance Services (when Medically Necessary)
Land/Air
30%
30%
(See note below)
Note: Care received Out-of-Network for an Emergency Medical Condition will be provided at the Network level of benefits if the following conditions apply: A medical or behavioral health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in one of the following conditions: (1) Placing the health of the individual or the health of another person (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (2) Serious impairment to bodily functions; or (3) Serious 12
Benefits
Member Responsibility
Network Out-of-Network
Note: All Covered Services are subject to the Deductible and applicable Coinsurance unless otherwise specified in this booklet
dysfunction of any bodily organ or part. If an Out-of-Network Provider is used, however, You are responsible to pay the difference between the Maximum Allowed Amount and the amount the Out-of- Network Provider charges.
Eye Care - Non-Routine
Office Visit – medical eye care exams (treatment of disease or Injury to the eye)
30%
50%
Hearing Care - Non-Routine
Office Visit – Audiometric exam/hearing evaluation test 30% 50% Home Health Care Services
16 hour per day maximum
30% 50%
Private Duty Nursing 30% 50%
Hospice Care Services
(Bereavement Counseling Not Covered)
30% 50%
Hospital Inpatient Services – Precertification
Required
Room and Board (Semiprivate or ICU/CCU) 30%
50%
Hospital Services and Supplies (x-ray, lab, anesthesia, surgery (Precertification required), Inpatient
Physical Therapy, etc.)
30%
50%
Pre-Admission Testing 30% 50%
Maternity Care & Other Reproductive Services
Physician’s Office:
Global Care (includes pre-and post-natal, delivery): Primary Care Physician (includes obstetrician and
gynecologist) Coinsurance
30%
50%
Specialist Physician Coinsurance 30% 50%
Physician Hospital/Birthing Center Services (Precertification required) Physician’s Services 30% 50%
13
Benefits
Member Responsibility
Network Out-of-Network
Note: All Covered Services are subject to the Deductible and applicable Coinsurance unless otherwise specified in this booklet
Newborn Nursery Services (well baby care) 30% 50%
Note: Newborn stays in the Hospital after the mother is discharged, as well as any stays exceeding 48 hours for a vaginal delivery or 96 hours for a cesarean section, must be pre-certified Infertility Services
Note: Covered for services to diagnose infertility only; treatment of infertility is not covered.
30% 50%
Sterilization Services (Precertification required
for Inpatient procedures)
Sterilizations for women will be covered under the “Preventive Services” benefit. Please see that section in Benefits for further details.
Medical Supplies and Equipment
Medical Supplies 30% 50%
Durable Medical Equipment 30% 50%
Orthotics
Foot and shoe
Note: Foot orthotics limited to $300 per year
Note: Foot orthotics limited to $600 per lifetime
30% 50%
Prosthetic Appliances (external) 30% 50%
Nutritional Counseling for Diabetes 30% 50%
Nutritional Counseling (Non Diabetic) 30% 50%
Maximum visits per calendar year combined Network
and Out-of-Network
3 visits
Nutritional Counseling for Eating Disorders 30% 50% Outpatient Hospital/Facility Services
Outpatient Facility 30% 50%
Lab and X-Ray Services 30% 50%
14
Benefits
Member Responsibility
Network Out-of-Network
Note: All Covered Services are subject to the Deductible and applicable Coinsurance unless otherwise specified in this booklet
Outpatient Physician Services (surgeon,
anesthesiologist, radiologist, pathologist, etc.)
30% 50%
Physician Services (Home and Office Visits)
Primary Care Physician (per visit) 30% 50%
Specialist Physician (per visit) 30% 50%
Important Note on Office Visits at an Outpatient Facility: If you have an office visit with your Primary Care Physician or Specialty Care Physician at an Outpatient Facility (e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under the “Outpatient Facility” section earlier in this Schedule. Please refer to that section for details on the cost shares (e.g., Deductibles, Coinsurance) that will apply.
Office Surgery 30% 50%
Online Visits from LiveHealth Online Provider (Other than Behavioral Health & Substance Abuse; see
Behavioral Health/Substance Abuse Care section
for further details)
Telehealth - Consultations with your physician
(PCP/Specialist) using visual and audio
(Computer, Smart Phone, Tablet)
Telephonic - Consultations with your physician
(PCP/Specialist) using audio only (Telephone)
30%
30%
30%
Out-of-Network and
non-LiveHealth Online
Providers – Not
Covered
50%
50%
Preventive Services Covered at 100% Not Covered
Skilled Nursing Facility 30% 50%
Maximum days (Combined with Inpatient
Physical Medical Rehabilitation)
60 days per calendar year combined Network and
Out-of-Network.
Surgical Services 30% 50%
Bariatric Surgery 30% Not Covered
Therapy Services (Outpatient)
Physical Therapy 30% 50%
Occupational Therapy 30% 50%
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Benefits
Member Responsibility
Network Out-of-Network
Note: All Covered Services are subject to the Deductible and applicable Coinsurance unless otherwise specified in this booklet
Speech Therapy 30% 50%
Cardiac Rehabilitation
36 day maximum per calendar year combined Network
and Out-of-Network
30% 50%
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Benefits
Member Responsibility
Network Out-of-Network
Note: All Covered Services are subject to the Deductible and applicable Coinsurance unless otherwise specified in this booklet
Manipulation Therapy
20 visit maximum per calendar year combined Network and Out-of-Network
30% 50%
Radiation Therapy 30% 50%
Chemotherapy 30% 50%
Respiratory Therapy 30% 50%
Vision Therapy Not Covered Not Covered
Note: Inpatient therapy services will be paid under the Inpatient Hospital benefit. Transplants
Any Medically Necessary human organ and stem
cell/bone marrow transplant and transfusion as
determined by the Claims Administrator including
necessary acquisition procedures, collection and
storage, including Medically Necessary preparatory myeloablative therapy.
The Center of Excellence requirements do not
apply to Cornea and kidney transplants; and any
Covered Services, related to a Covered Transplant
Procedure, received prior to or after the Transplant Benefit Period.
Note: Even if a Hospital is a Network Provider for other services, it may not be a Network Transplant Provider for these services. Please be sure to contact the Claims Administrator to determine which
Hospitals are Network Transplant Providers. (When
calling Member Services, ask to be connected with
the Transplant Case Manager for further information.) Center of
Excellence/Network
Transplant Provider
Out-of-Network
Transplant Provider
17
Benefits
Member Responsibility
Network Out-of-Network
Note: All Covered Services are subject to the Deductible and applicable Coinsurance unless otherwise specified in this booklet
Transplant Benefit Period Starts one day prior to a Covered Transplant
Procedure and
continues for the
applicable case
rate/global time period
(The number of days
will vary depending on
the type of transplant
received and the Center
of Excellence Network
Transplant Provider
agreement. Contact the
Member Services
number on Your
Identification Card and
ask for the Transplant
Case Manager for
specific Network
Transplant Provider
information.)
Starts one day prior to a
Covered Transplant
Procedure and
continues to the date of
discharge.
Covered Transplant Procedure during the
Transplant Benefit Period
Center of Excellence
Provider (BDCT)
100%
Other Network Provider
30%
Not applicable
50%
Care coordinated through a Center of Excellence BDCT Facility – not subject to Deductible When performed by Network Non BDCT Facility or Out-of-Network Transplant Provider (subject to Deductible). You are responsible for any charges from the Out-of-Network Transplant Provider which exceeds the Maximum Allowed Amount.
Bone Marrow & Stem Cell Transplant (Inpatient &
Outpatient)
Center of Excellence
Provider (BDCT)
100%
Other Network Provider
30%
Not applicable
50%
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Benefits
Member Responsibility
Network Out-of-Network
Note: All Covered Services are subject
Contact this candidate