Affordable Health Plans from BlueCross BlueShield of Tennessee by wanghonghx

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									Affordable Health Plans from
BlueCross BlueShield of Tennessee




         for the Lincoln Memorial University -
         DeBusk College of Osteopathic Medical Students
      LMU - DeBusk College of Osteopathic Medicine Health Care Plans for Students




Welcome
Your life is busy and BlueCross BlueShield of                  •	 Checkups	and	screenings	to	keep	you	healthy	at	
Tennessee wants to make it as easy as possible for                low cost or no cost.
you to receive care when you need it. That is why we           •	 Generous	maximum	coverage	up	to	a	$1,000,000	
offer you a choice of two affordable health plans to fit          lifetime benefit.
your lifestyle and meet your health care needs.
                                                               BlueCross BlueShield of Tennessee covers more
The plans provide:
                                                               Tennesseans than any other carrier in the state and
•	 Access	to	network	doctors	virtually	anywhere	               offers you a variety of qualified doctors, hospitals
   you go…in Tennessee, in the U.S., even in many              and other health care providers. Our strength and
   countries outside the U.S.                                  scope are among the reasons BlueCross BlueShield
•	 The	highest	level	of	benefits	when	you	use	health	          of Tennessee was selected to administer a health care
   care providers in the BlueCross BlueShield of               plan for the LMU - DeBusk College of Osteopathic
   Tennessee network.                                          Medicine.
•	 Freedom	to	choose	your	own	doctors	and	hospitals	
   – in-network or out-of-network.
                                                           1
      LMU - DeBusk College of Osteopathic Medicine Health Care Plans for Students


Answers at Your Fingertips
When you need answers, we’re here to help. We offer
a number of ways for you to access information.
bcbst.com
The health tools at our Web site can easily help you:
•	 Find	a	doctor
•	 Compare	the	cost	of	drugs
•	 Discover	money-saving	tips	on	drugs
•	 Compare	the	quality	of	hospitals
Nurseline
Get	health	advice	when	you	need	it	most	with	our	24/7	
Nurseline.	24/7	Nurseline	is	a	free	service	provided	by	
BlueCross BlueShield of Tennessee that enables you
to speak with a Registered Nurse any time of day or
night – about any type of health condition – and help
you decide what kind of care you need.

Consumer Advisors
Consumer	Advisors	can	help	you	with	day-to-day	
type information. It is important for our members to
understand their basic benefits, doctor and hospital
availability and other information available to you to
support effective decision-making.

Health Care Across the State or Around                         Eligibility
the World – BlueCard                                           The qualifications for coverage are quite simple,
Whether you’re at home, at school or on vacation,              as long as you are a full-time student in the LMU -
our plans give you access to Blue Network providers            DeBusk College of Osteopathic Medicine you are
wherever you go. BlueCard PPO and BlueCard                     eligible for coverage with BlueCross BlueShield of
Worldwide are programs that give you access to                 Tennessee.
doctors and hospitals almost everywhere. More than
95 percent of all U.S. doctors and hospitals participate       Summary of Benefits
with BlueCross BlueShield plans. Outside the U.S., you         You will enjoy the highest level of benefits by choosing
have	access	to	doctors	and	hospitals	in	more	than	200	         a health care provider in the BlueCross BlueShield of
countries and territories.                                     Tennessee network of doctors and hospitals. When
                                                               you choose network providers in Tennessee or the
Remember to always carry your member ID card and
                                                               contiguous counties, you pay only copayments,
show it each time you request services from a network
                                                               deductibles and coinsurance that may apply and any
provider. Your ID card shows any copay amounts, if
                                                               services that are not covered by the plan.
applicable, and your plan’s network. In an emergency,
go directly to the nearest hospital. Show your member          You are not locked into using a doctor in the
ID card at an emergency room if you have a health              BlueCross BlueShield of Tennessee network. You are
care crisis. Emergency care is covered anytime,                free to use the health care providers of your choice.
anywhere	(some	exclusions	apply).                              However, using out-of-network providers can result in
                                                               higher out of pocket costs for you.




                                                           2
            LMU - DeBusk College of Osteopathic Medicine Health Care Plans for Students - Option 1

PPO Benefits                                                                                           Blue Network S                                                              Effective Date: August 1, 2010
      Premium	payments	are	due	Aug.	1,	2010	&	Jan.	1,	2011                                                               Student:	$1,282.38                                         Student	+	Spouse:	$2,693.04
                                                                                                                         Student	+	Child(ren):	$2,308.32	                           Family:	$3,847.14
 Benefit Highlighs                                                                                                    In-Network Benefits                                         Out-of-Network Benefits [3]
 Annual Deductible
    Individual                                                                                                                                $500	                                                     $1,000
    Family                                                                                                                                   	$1,000	                                                   $2,000
 Annual Out-of-Pocket Maximum
    Individual                                                                                                                              $4,000	                                                     $8,000
    Family	                                                                                                                                 $8,000	                                                    $16,000
 Dependent Age Limit                                                                                                                      To	age	26                                                  To	age	26
 Lifetime Maximum                                                                                                                         $1,000,000                                                 $1,000,000
 Pre-Existing Condition Waiting Period [1]                                                                                                12	months                                                  12	months
 4th Quarter Deductible Carryover Provision                                                                                                Included                                                   Included
 Office Visits
    Office	Visits	[2]	                                                                                                              $25/$40	Copay                                           60%	after	Deductible
    LMU-DCOM Division of Out-Patient Services                                                                                      100%	(no	copay)                                            100%	(no	copay)
    Routine	Diagnostic	Lab,	X-Ray	&	Injections                                                                                   No	Additional	Copay                                        60%	after	Deductible
    Advanced	Radiological	Imaging	[6]	[12]	                                                                                      80%	after	Deductible                                       60%	after	Deductible
    Provider-Administered	Specialty	Drugs	[11]	                                                                                      $100	Copay                                             60%	after	Deductible
 Preventive Health Care Services
   Well	Child	Care	(to	age	6)	                                                                                                       $25	Copay                                              60%	after	Deductible
   Annual	Well	Woman	Exam                                                                                                            $25	Copay                                              60%	after	Deductible
   Annual	Mammography	Screening                                                                                                  No	Additional	Copay                                        60%	after	Deductible
   Annual	Cervical	Cancer	Screening                                                                                              No	Additional	Copay                                        60%	after	Deductible
   Prostate Cancer Screening                                                                                                     No	Additional	Copay                                        60%	after	Deductible
   Immunizations	(to	age	6)	                                                                                                     No	Additional	Copay                                        60%	after	Deductible
   Well	Care	Services	(ages	6	and	up)	                                                                                               $25	Copay                                              60%	after	Deductible
   $300	Annual	Limit
 Services Received at a Facility (includes professional and facility charges)
   Inpatient	Services	[4]	                                                                                                      80%	after	Deductible                                        60%	after	Deductible
   Outpatient	Surgery	[5]	                                                                                                      80%	after	Deductible                                        60%	after	Deductible
   Routine Diagnostic Services-Outpatient                                                                                       100%	(no	Deductible)                                        60%	after	Deductible
   Advanced	Radiological	Imaging-Outpatient	[6]	[12]	                                                                           80%	after	Deductible                                        60%	after	Deductible
   Provider-Administered	Specialty	Drugs	[11]	                                                                                  80%	after	Deductible                                        60%	after	Deductible
   Other	Outpatient	Services	[7]	                                                                                               80%	after	Deductible                                        60%	after	Deductible
   Emergency	Care	Services	[9]                                                                                                  80%	after	$120	Copay                                        80%	after	$120	Copay
   Emergency	Care	Advanced	Radiological	Imaging	[6]	                                                                            80%	after	Deductible                                        80%	after	Deductible
 Medical Equipment
   Durable Medical Equipment                                                                                                     80%	after	Deductible                                       60%	after	Deductible
   Prosthetics                                                                                                                   80%	after	Deductible                                       60%	after	Deductible
   Orthotic	Appliances                                                                                                           80%	after	Deductible                                       60%	after	Deductible
 Behavioral Health
   Inpatient: Unlimited days per annual benefit period                                                                           80%	after	Deductible                                       60%	after	Deductible
   Outpatient: Unlimited visits per annual benefit period                                                                         $25	Copay	per	visit                                       60%	after	Deductible
 Therapeutic Services [8]
   Therapy	(Limited	to	30-36	visits	per	annual	benefit	period	per	therapy	type)	                                                 80%	after	Deductible                                       60%	after	Deductible
 Ambulance Service                                                                                                               80%	after	Deductible                                       80%	after	Deductible
 Pharmacy
   Prescription	Drugs	[10]	[13]                                                                                           $10/$35/$50	Copay	(Subject	to	a	Calendar	Year	benefit	Maximum	of	$1500)
   Specialty	Drugs	[10]	[11]	[13]                                                                                         Preferred	Vendors	-	$100	Copay	/	Non-Preferred	Vendors	-	$200	Copay
Notes:
1.	 HIPAA	regulations	apply.	A	Group	enrollee’s	pre-existing	condition	waiting	period	can	be	reduced	by	the	enrollee’s	applicable	‘creditable	coverage’.	
2.	 The	lower	copay	applies	to	Family	Practice,	General	Practice,	Internal	Medicine,	OB/Gyn,	Pediatrics,	Nurse	Practitioners	and	Physician	Assistants.
3.	 Out-of-network	benefit	payment	based	on	BlueCross	BlueShield	of	Tennessee	maximum	allowable	charge.	You	are	responsible	for	paying	any	amount	exceeding	the	maximum	allowable	charge.
4.	 Services	require	prior	authorization.	When	using	network	providers	outside	Tennessee	and	all	out-of-network	providers,	benefits	will	be	reduced	to	50%	if	prior	authorization	is	not	obtained	and	services	are	medically	necessary.	If	
     services are not medically necessary no benefits will be provided.
5.	 Surgeries	include	incisions,	excisions,	biopsies,	injection	treatments,	fracture	treatments,	applications	of	casts	and	splints,	sutures,	and	invasive	diagnostic	services	(e.g.,	colonoscopy,	sigmoidoscopy	and	endoscopy).	
6.	 CAT	scans,	PET	Scans,	MRIs,	nuclear	medicine	and	other	similar	technologies.
7.	 Includes	services	such	as	chemotherapy,	radiation	therapy,	and	renal	dialysis.
8.	 Physical,	speech,	manipulative,	and	occupational	therapies	are	limited	to	20	visits	per	therapy	type	per	annual	benefit	period.	Cardiac	and	pulmonary	rehabilitative	therapies	are	limited	to	36	visits	per	therapy	type	per	annual	
     benefit period.
9. Copay, if applicable, waived if admitted to hospital.
10.	 See	attached	rider	for	Pharmacy	exclusions	and	Specialty	Drug	vendors.
11.	 Refer	to	www.bcbst.com	for	Specialty	Pharmacy	Drug	List.
12.	 Requires	prior	authorization.
13.	 Copay	per	prescription,	up	to	30	day	supply.




                                                                                                                    3
                                                                                                                                                                                                                         Option 2

PPO Benefits                                                                                            Blue Network S                                                              Effective Date: August 1, 2010
      Premium	payments	are	due	Aug.	1,	2010	&	Jan.	1,	2011                                                                 Student:	$1,015.08                                        Student	+	Spouse:	$2,131,74
                                                                                                                           Student	+	Child(ren):	$1,827.18                           Family:	$3,045.24
 Benefit Highlights                                                                                                     In-Network Benefits                                        Out-of-Network Benefits [3]
 Annual Deductible
    Individual                                                                                                                                $2,500	                                                   $5,000
    Family                                                                                                                                    $5,000                                                    $10,000
 Annual Out-of-Pocket Maximum
    Individual                                                                                                                              	$5,000	                                                     $10,000
    Family	                                                                                                                                 $10,000                                                     	$20,000
    Dependent	Age	Limit                                                                                                                    To	age	26                                                   To	age	26
 Lifetime Maximum                                                                                                                         $1,000,000                                                  $1,000,000
 Pre-Existing Condition Waiting Period [1                                                                                                 12	months]                                                  12	months]
 4th Quarter Deductible Carryover Provision                                                                                                Included                                                    Included
 Office Visits
    Office	Visits	[2]	                                                                                                               $35/$50	Copay	                                          60%	after	Deductible
    LMU-DCOM Division of Out-Patient Services                                                                                       100%	(no	copay)	                                           100%	(no	copay)
    Routine	Diagnostic	Lab,	X-Ray	&	Injections	                                                                                   No	Additional	Copay	                                       60%	after	Deductible
    Advanced	Radiological	Imaging	[6]	[12]	                                                                                       80%	after	Deductible	                                      60%	after	Deductible
    Provider-Administered	Specialty	Drugs	[11]	                                                                                       $100	Copay	                                            60%	after	Deductible
 Preventive Health Care Services
    Well	Child	Care	(to	age	6)	                                                                                                       $35	Copay	                                             60%	after	Deductible
    Annual	Well	Woman	Exam	                                                                                                           $35	Copay	                                             60%	after	Deductible
    Annual	Mammography	Screening	                                                                                                 No	Additional	Copay	                                       60%	after	Deductible
    Annual	Cervical	Cancer	Screening	                                                                                             No	Additional	Copay                                        60%	after	Deductible
    Prostate Cancer Screening                                                                                                     No	Additional	Copay	                                       60%	after	Deductible
    Immunizations	(to	age	6)	                                                                                                     No	Additional	Copay	                                       60%	after	Deductible
    Well	Care	Services	(ages	6	and	up)	$300	Annual	Limit	                                                                             $35	Copay	                                             60%	after	Deductible
 Services Received at a Facility (includes professional and facility charges)
    Inpatient	Services	[4]	                                                                                                      80%	after	Deductible	                                        60%	after	Deductible
    Outpatient	Surgery	[5]	                                                                                                      80%	after	Deductible	                                        60%	after	Deductible
    Routine Diagnostic Services-Outpatient                                                                                       100%	(no	Deductible)	                                       60%	after	Deductible
    Advanced	Radiological	Imaging-Outpatient	[6]	[12]	                                                                           80%	after	Deductible	                                        60%	after	Deductible
    Provider-Administered	Specialty	Drugs	[11]	                                                                                  80%	after	Deductible	                                        60%	after	Deductible
    Other	Outpatient	Services	[7]	                                                                                               80%	after	Deductible                                        	60%	after	Deductible
    Emergency	Care	Services	[9]	                                                                                                 80%	after	$120	Copay	                                       80%	after	$120	Copay
    Emergency	Care	Advanced	Radiological	Imaging	[6]	                                                                            80%	after	Deductible	                                        80%	after	Deductible
 Medical Equipment
    Durable Medical Equipment                                                                                                     80%	after	Deductible	                                      60%	after	Deductible
    Prosthetics                                                                                                                   80%	after	Deductible	                                      60%	after	Deductible
    Orthotic	Appliances	                                                                                                          80%	after	Deductible	                                      60%	after	Deductible
 Behavioral Health
    Inpatient: Unlimited days per annual benefit period                                                                           80%	after	Deductible	                                      60%	after	Deductible
    Outpatient: Unlimited visits per annual benefit period                                                                         	$35	Copay	per	visit	                                     60%	after	Deductible
 Therapeutic Services [8]
    Therapy	(Limited	to	30-                                                                                                       80%	after	Deductible	                                      60%	after	Deductible
 Ambulance Service                                                                                                                80%	after	Deductible	                                      80%	after	Deductible
 Pharmacy
    Prescription	Drugs	[10]	[13]                                                                                           $10/$35/$50	Copay	(Subject	to	a	Calendar	Year	benefit	Maximum	of	$1500)
    Specialty	Drugs	[10]	[11]	[13]                                                                                         Preferred	Vendors	-	$100	Copay	/	Non-Preferred	Vendors	-	$200	Copay
Notes:
1.	HIPAA	regulations	apply.	A	Group	enrollee’s	pre-existing	condition	waiting	period	can	be	reduced	by	the	enrollee’s	applicable	‘creditable	coverage’.
2.	 The	lower	copay	applies	to	Family	Practice,	General	Practice,	Internal	Medicine,	OB/Gyn,	Pediatrics,	Nurse	Practitioners	and	Physician	Assistants.
3.	 Out-of-network	benefit	payment	based	on	BlueCross	BlueShield	of	Tennessee	maximum	allowable	charge.	You	are	responsible	for	paying	any	amount	exceeding	the	maximum	allowable	charge.
4.		 Services	require	prior	authorization.	When	using	network	providers	outside	Tennessee	and	all	out-of-network	providers,	benefits	will	be	reduced	to	50%	if	prior	authorization	is	not	obtained	and	services	are	medically	necessary.	If	
     services are not medically necessary no benefits will be provided.
5.		 Surgeries	include	incisions,	excisions,	biopsies,	injection	treatments,	fracture	treatments,	applications	of	casts	and	splints,	sutures,	and	invasive	diagnostic	services	(e.g.,	colonoscopy,	sigmoidoscopy	and	endoscopy).
6.	 CAT	scans,	PET	Scans,	MRIs,	nuclear	medicine	and	other	similar	technologies.
7.	 Includes	services	such	as	chemotherapy,	radiation	therapy,	and	renal	dialysis.
8.		 Physical,	speech,	manipulative,	and	occupational	therapies	are	limited	to	20	visits	per	therapy	type	per	annual	benefit	period.	Cardiac	and	pulmonary	rehabilitative	therapies	are	limited	to	36	visits	per	therapy	type	per	annual	
     benefit period.
9. Copay, if applicable, waived if admitted to hospital.
10.	 See	attached	rider	for	Pharmacy	exclusions	and	Specialty	Drug	vendors.
11.	 Refer	to	www.bcbst.com	for	Specialty	Pharmacy	Drug	List.
12.		Requires	prior	authorization.
13.		Copay	per	prescription,	up	to	30	day	supply.




                                                                                                                    4
           LMU - DeBusk College of Osteopathic Medicine Health Care Plans for Students

Exclusions From Coverage                                           •Chelation	therapy,	except	for	control	of	ventricular	
                                                                      arrhythmias or heart block associated with digitalis
                                                                                                                                      •	 Diagnostic	services	not	ordered	by	a	Practitioner;
                                                                                                                                      •	 Pharmaceuticals	purchased	with	a	prescription	except	
•	 Services	or	supplies	not	listed	as	Covered	Services	in	the	        toxicity;	Emergency	treatment	of	hypercalcemia;	extreme	           those dispensed at a participating facility, unless listed in
   Evidence	of	Coverage	(EOC);                                        conditions	of	metal	toxicity,	including	thalassemia	               a	separate	rider;
•	 Services	or	supplies	that	are	not	Medically	Necessary	and	         with	hemosiderosis;	Wilson’s	disease	(hepatolenticular	         •	 Pharmaceuticals	that	may	be	purchased	without	a	
   Appropriate;                                                       degeneration);	and	lead	poisoning;                                 prescription;
•	 Services	or	supplies	that	are	Investigational;                  •	 Vagus	nerve	stimulation	for	the	treatment	of	depression;        •	 Self-administered	Specialty	Drugs	as	identified	on	the	
•	 Illness	or	injury	resulting	from	war,	that	occurred	before	     •	 Artificial	intervertebral	disc;                                    Plan’s	Specialty	Drug	list,	except	as	may	be	Covered	by	a	
   Your Coverage began under this EOC and that is                  •	 Balloon	sinuplasty	for	treatment	of	chronic	sinusitis;             separate	Rider;
   Covered by veteran’s benefit or other coverage for which        •	 Treatment	for	benign	gynecomastia;                              •	 FDA-approved	drugs	used	for	purposes	other	than	those	
   You	are	legally	entitled;                                       •	 Treatment	for	hyperhidrosis;                                       approved	by	the	FDA,	unless	the	drug	is	recognized	for	
•	 Self	treatment	or	training;                                     •	 Percutaneous	intradiscal	eletrothermal	annuloplasty	and	           the treatment of the particular indication in one of the
•	 Staff	consultations	required	by	hospital	or	other	facility	        percutaneous intradiscal radiofrenecy thermocoagulation            standard	reference	compendia;
   rules;                                                             to	treat	chronic	discogenic	back	pain;                          •	 Services,	surgeries	and	supplies	to	detect	or	correct	
•	 Services	that	are	free;                                         •	 Office	visits,	physical	exams	and	related	immunizations	           refractive	errors	of	the	eyes;
•	 Treatment	of	work	related	illness	or	injury;                       and	tests,	when	required	solely	for:	sports;	camp;	             •	 Eyeglasses,	contact	lenses	and	examinations	for	the	
•	 Personal,	physical	fitness,	recreational	or	convenience	           employment;	travel;	insurance;	marriage	or	legal	                  fitting	of	eyeglasses	and	contact	lenses;
   items	and	services,	even	if	ordered	by	a	Practitioner;             proceedings;                                                    •	 Eye	exercises	and/or	therapy;
•	 Services	or	supplies,	including	those	related	to	a	Hospital	    •	 Routine	foot	care	for	the	treatment	of:	flat	feet;	corns;	      •	 Visual	training;
   Confinement, received before Your effective date for               bunions;	calluses;	toenails;	fallen	arches;	and	weak	feet	or	   •	 Charges	exceeding	the	total	cost	of	the	Maximum	
   Coverage	with	this	Plan;                                           chronic	foot	strain;                                               Allowable	Charge	to	purchase	Durable	Medical	
•	 Services	or	supplies	received	after	Your	Coverage	              •	 Foot	orthotics,	shoe	inserts	and	custom	made	shoes,	               Equipment;
   under this Plan ceases for any reason, even though the             except	as	required	by	law	for	diabetic	patients	or	as	a	        •	 Unnecessary	repair,	adjustment	or	replacement	or	
   expenses	relate	to	a	condition	that	began	while	You	were	          part	of	a	leg	brace;                                               duplicates	of	any	such	equipment;
   Covered;                                                        •	 Dental	procedures,	except	as	otherwise	indicated	in	the	        •	 Supplies	and	accessories	that	are	not	necessary	for	the	
•	 Services	or	supplies	received	in	a	dental	or	medical	              EOC;                                                               effective	functioning	of	the	Covered	equipment;
   department maintained by or on behalf of the employer,          •	 Inpatient	stays	primarily	for	therapy	(such	as	physical	or	     •	 Items	to	replace	those	that	were	lost,	damaged,	stolen	or	
   mutual	benefit	association,	labor	union	or	similar	group;          occupational	therapy);                                             prescribed	as	a	result	of	new	technology;
•	 Services	or	charges	to	complete	a	claim	form	or	to	             •	 Private	room	when	not	Authorized	by	the	Plan	and	room	          •	 Items	that	require	or	are	dependent	on	alteration	of	
   provide	medical	records	or	other	administrative	functions;         and	board	charges	are	in	excess	of	semi-private	room;              home,	workplace	or	transportation	vehicle;
•	 Telephone	consultations,	e-mail	or	web	based	                   •	 Emergency	treatment	of	a	chronic,	non-	Emergency	               •	 Motorized	scooters,	exercise	equipment,	hot	tubs,	pool,	
   consultations, or telemedicine services, or charges for            condition,	where	the	symptoms	have	existed	over	a	                 saunas;
   failure	to	keep	a	scheduled	appointment;                           period of time, and a prudent layperson who possesses           •	 “Deluxe”	or	“enhanced”	equipment;
•	 Court	ordered	examinations	and	treatment,	unless	                  an average knowledge of health and medicine would not           •	 Computerized	or	gyroscopic	mobility	systems,	roll	about	
   Medically	Necessary;                                               believe	it	to	be	an	Emergency;                                     chairs, geriatric chairs, hip chairs, and seat lifts of any
•	 Room,	board	and	general	nursing	care	rendered	on	the	           •	 Ambulance	transportation	for	Your	convenience,	that	is	            kind;
   date of discharge, unless admission and discharge occur            not essential to reduce the probability of harm to You, or      •	 Patient	lifts,	auto	tilt	chairs,	air	fluidized	beds,	or	air	
   on	the	same	day;                                                   when	You	are	not	transported	to	a	facility;                        flotation	beds,	unless	approved	by	Case	Management	for	
•	 Benefits	for	Pre-existing	Conditions	are	excluded	until	        •	 Behavioral	Health	Services	except	as	specified	in	                 a	Member	who	is	in	Case	Management;
   any	Pre-existing	Condition	Waiting	Periods	have	been	              separate	Rider;                                                 •	 Diabetic	treatments	or	supplies	that	are	not	prescribed	
   met;                                                            •	 Services	or	supplies	that	are	designed	to	create	a	                and certified by a Practitioner as being Medically
•	 Charges	in	excess	of	the	Maximum	Allowable	Charge	                 pregnancy, enhance fertility or improve conception                 Necessary;
   for	Covered	Services	or	any	charges	which	exceed	the	              quality;                                                        •	 Diabetic	supplies	not	required	by	state	statute;
   Lifetime	Maximum;                                               •	 Reversals	of	sterilizations;                                    •	 Hearing	aids;
•	 Any	service	stated	in	the	EOC	as	a	non-	Covered	Service	        •	 Induced	abortion	unless:	the	health	care	Practitioner	          •	 Prosthetics	primarily	for	cosmetic	purposes,	including	but	
   or	limitation;                                                     certifies in writing that the pregnancy would endanger             not	limited	to	wigs,	or	other	hair	prosthesis	or	transplants;
•	 Charges	for	services	performed	by	You	or	Your	spouse,	or	          the	life	of	the	mother;	the	pregnancy	is	a	result	of	           •	 Replacements	of	contacts	after	the	initial	pair	have	been	
   Your	or	Your	spouse’s	parent,	sister,	brother	or	child;            rape	or	incest;	the	fetus	is	not	viable;	or	the	fetus	has	         provided	following	cataract	surgery;
•	 Any	charges	for	handling	fees;                                     been diagnosed with a lethal or otherwise significant           •	 Items	such	as	non-treatment	services	or:	routine	
•	 Nicotine	replacement	therapy	and	aids	to	smoking	                  abnormality;                                                       transportation;	homemaker	or	housekeeping	services;	
   cessation	including,	but	not	limited	to,	patches;               •	 Services,	supplies	or	prosthetics	primarily	to	improve	            behavioral	counseling;	supportive	environmental	
•	 Safety	items,	or	items	to	affect	performance	primarily	in	         appearance;                                                        equipment;	Maintenance	Care	or	Custodial	Care;	
   sports-related	activities;                                      •	 Surgeries	to	correct	or	repair	the	results	of	a	prior	             social	casework;	meal	delivery;	personal	hygiene;	and	
•	 Services	or	supplies,	including	bariatric	surgery,	for	            Surgical Procedure, the primary purpose of which was to            convenience	items;
   weight loss or to treat obesity, even if You have other            improve appearance, even if that prior procedure was a          •	 Services	such	as:	homemaker	or	housekeeping	services;	
   health conditions that might be helped by weight loss or           Covered	Service;                                                   meals;	convenience	or	comfort	items	not	related	to	the	
   reduction	of	obesity;                                           •	 Surgeries	and	related	services	to	change	gender	                   illness;	supportive	environmental	equipment;	private	duty	
•	 Any	re-operation	or	surgery	related	to	bariatric	surgery,	         (transsexual	Surgery);                                             nursing;	routine	transportation;	and	funeral	or	financial	
   including, but not limited to, complications of bariatric       •	 Custodial,	domiciliary	or	private	duty	nursing	services;           counseling;
   surgery	or	body	remodeling	following	weight	loss;               •	 Cognitive	rehabilitation;                                       •	 Supplies	that	can	be	obtained	without	a	prescription	
•	 Services	or	supplies	related	to	treatment	of	complications	     •	 Therapy/Rehabilitative	treatment	beyond	what	can	                  (except	for	diabetic	supplies).	
   (except	Complications	of	Pregnancy)	that	are	a	direct	             reasonably	be	expected	to	significantly	improve	
   or closely related result of a Member’s refusal to accept          health, including therapeutic treatments for ongoing            Please refer to the Evidence
   treatment, medicines, or a course of treatment that a
   Provider has recommended or has been determined to
                                                                      maintenance	or	palliative	care;
                                                                   •	 Enhancement	therapy	that	is	designed	to	improve	Your	
                                                                                                                                      of Coverage for Complete
   be Medically Necessary, including leaving an inpatient             physical	status	beyond	Your	preinjury	or	pre-illness	state;     description of benefits and
   medical facility against the advice of the treating             •	 Complementary	and	alternative	therapeutic	services,	
   physician;                                                         including,	but	not	limited	to:	massage	therapy;	                exclusions.
•	 Cosmetic	services;                                                 acupuncture;	craniosacral	therapy;	cognitive	
•	 Blepharoplasty	and	browplasty,	except	for:	correction	of	          rehabilitation;	vision	exercise	therapy;	and	neuromuscular	
   injury to the orbital area resulting from physical trauma          reeducation;
   or non-cosmetic Surgical Procedures (e.g., removal              •	 Therapy	modalities	that	do	not	require	the	attendance	or	
   of	malignancies);	treatment	of	edema	and	irritation	               supervision	of	a	licensed	therapist;
   resulting	from	Graves’	disease;	or	correction	of	trichiasis,	   •	 Behavioral	therapy,	play	therapy,	communication	therapy,	
   ectropion,	or	entropion	of	the	eyelids;                            and therapy for self correcting language dysfunctions as
•	 Services	and	charges	related	to	the	care	of	the	biological	        part of speech therapy, physical therapy or occupational
   mother of an adopted child, if the biological mother is            therapy	programs;
   not a Member. Services and charges relating to surrogate        •	 Organ	transplant	and	related	services	that	were	not	
   parenting;                                                         Authorized	through	Transplant	Case	Management;
•	 Sperm	preservation;                                             •	 Transplant	related	charges	in	excess	of	the	Transplant	
•	 Orthognathic	Surgery;                                              Maximum	Allowable	Charge;
•	 Maintenance	Care;                                               •	 Donor	services	including	screening	and	assessment	
•	 Private	duty	nursing;                                              procedures	that	have	not	received	Prior	Authorization;
•	 Pharmacogenetic	testing	or	pharmacogenomics;                    •	 Removal	of	an	organ	from	a	Member	for	purposes	of	
•	 Treatment	of	sexual	dysfunction,	regardless	of	cause;              transplantation	into	another	person,	except	as	Covered	
•	 Services	or	supplies	related	to	complications	of	                  by	the	Donor	Organ	Procurement	provision;
   cosmetic procedures, complications of bariatric surgery,        •	 Routine	dental	care	and	related	services;
   re-operation of bariatric surgery or body remodeling            •	 Treatment	for	correction	of	underbite,	overbite,	and	
   following	weight	loss;                                             misalignment	of	the	teeth;
•	 Methadone	maintenance	therapy	and	buprenorphine	                •	 Extraction	of	impacted	teeth,	including	wisdom	teeth;
   maintenance	therapy;                                            •	 Diagnostic	services	that	are	not	Medically	Necessary	and	
•	 Cranial	orthosis,	including	helmet	or	headband,	for	the	           Appropriate;
   treatment	of	plagiocephaly;
**Services received from Lincoln Memorial University - DeBusk College of Medicine Department of Outpatient Service will be paid at 100 percent.
                                                                                                 5
      LMU - DeBusk College of Osteopathic Medicine Health Care Plans for Students


Behavioral Health Benefits
Mental Health/Substance Abuse Treatment
BlueCross BlueShield of Tennessee provides you with
a quality behavioral health program, in addition to
substance abuse treatment.
In-network:		    Inpatient	-	80%	after	deductible;	
                 Outpatient - Copay
Out-of-network: Subject to out-of-network deductible
                &	coinsurance
Inpatient services require prior authorization. Out-
of-network	benefits	are	provided	at	50%	when	prior	
authorization is not obtained.
Inpatient care management is included.

Mental Health Medication Management Benefit
Outpatient behavioral health visits for the purpose
of Medication Management do not count toward the
number of mental health outpatient visits per year.
Medication Management includes prescription, use
and review of medication.
                                                             is in the network. If you choose to use providers who
Please remember that all inpatient behavioral                are not in the behavioral health network, your benefits
health care, both routine and emergency, must be             may be reduced. Behavioral health providers include
authorized by BlueCross BlueShield of Tennessee’s            experienced	professionals,	programs,	and	facilities	to	
Behavioral Health Services.                                  meet	your	needs.	Any	information	you	provide	will	be	
                                                             confidential.
Emergency Mental Health or Substance Abuse Care              If you are outside the State of Tennessee and need
In an emergency, go to the nearest network facility          behavioral health care you must:
or to the emergency room of the closest medical
                                                             •	 For	Inpatient	care,	have	the	hospital	call	
hospital.	An	emergency	admission	to	the	hospital	
                                                                Behavioral	Health	Services	within	24	hours.
does not need to be pre-approved, but you or the
hospital must call Behavioral Health Services within         •	 For	Outpatient	care,	beginning	with	the	9th	visit,	
24	hours.                                                       call Behavioral Health Services to request Prior
                                                                Authorization
Access To Services
                                                             •	 Outpatient professional visits beginning with the
If you or a covered family member needs help, call the          9th	visit.	Outpatient	visits	1-8	do	not	require	Prior	
Behavioral Health Services Help Line phone number               Authorization.
listed on the back of your BlueCross Blue Shield of
Tennessee ID card. This toll-free number offers
                                                             To determine the network status of a provider in
assistance 24 hours a day, seven days a week, 365
                                                             the state in which you wish to seek care, call the
days a year.
                                                             Behavioral Health Services number on the back
For	inpatient	referral	and	inpatient	or	outpatient	          of your ID card and ask to speak with a BlueCross
prior authorization please call the telephone number         BlueShield of Tennessee customer service
on the back of your ID card and a care manager will          representative. This call should be made between
direct you to a participating provider. Consult your         the	hours	of	8:30	a.m.	and	5:30	p.m.	Eastern,	Monday	
directory to determine whether a particular provider         through	Friday.	


                                                         6
      LMU - DeBusk College of Osteopathic Medicine Health Care Plans for Students


Prescription Drug Benefits
$10/$35/$50 Prescription Drug Plan With $1,500               Non-Preferred Brand Drugs- your copay is $50
Calendar Year Benefit Maximum                                When your doctor prescribes a brand drug that is not
Pharmacy benefits are often a very important part of         on the Preferred Drug list, you pay the highest copay
a health insurance program. BlueCross BlueShield of          of	$50.
Tennessee	offers	you	an	excellent	and	inexpensive	
pharmacy benefit, which is important while you’re in         Pricing at Participating Pharmacies
school. When you need a prescription filled you will         When a member receives a prescription at a
only	pay	a	$10	copayment	for	generic	drugs.	Drugs	           pharmacy, he or she typically pays the appropriate
on	the	Preferred	Drug	List	are	a	$35	copayment	and	          copayment. Members pay less than the copayment if
non-preferred	drugs	are	a	$50	copayment.	(Prices	            the pharmacy’s usual price for the drug is less than the
based	on	30-day	supply.)	                                    copayment.
The copayment is the amount you pay to a network
                                                             Choosing a Brand when a Generic Equivalent is
pharmacy for each prescription you have filled. Your
                                                             Available
copayment is dependent upon which brand level of
drug you choose.                                             You’ll always save money when using generics.
                                                             In fact, all you pay is the generic copay. But if
Prescription drug benefits are limited to $1,500             you choose a brand-name drug when a generic
per calendar year. The drug copay is not included in         equivalent is available, you must pay the generic
the	benefit	maximum.                                         copay plus the cost difference between the brand-
                                                             name drug and generic drug.
Example:
Generic	Drug	A	Total	Cost	                =	 $50
Member	Copay	Amount	                      =	 $10
Amount	Applied	to	Annual	Benefit	Maximum	 =	 $40
Once	the	calendar	year	benefit	maximum	has	been	
reached, there is no additional prescription drug
coverage available for that year.

Generic Drugs- your copay is $10
Generic	drugs	offer	the	best	value.	A	generic	drug	is	
a safe and effective alternative to a brand name drug.
You pay the lowest copay when you choose a generic
drug. When your doctor writes your prescription, ask
about using a generic drug.
Generic	equivalents	are	made	with	the	same	active	
ingredients and produce the same effects in the body
as their brand-name equivalents. The difference?
Just	the	name	and	price	–	and	generics	cost	less.	
BlueCross BlueShield of Tennessee encourages the
use of generic drugs by offering lower copayments
when choosing generics.

Preferred Brand Drugs- your copay is $35
The Preferred Drug List is a list of therapeutically
sound, cost-effective drugs and is provided to
encourage the use of certain drugs within a
therapeutic class. When your doctor prescribes a
preferred	brand	drug,	your	copay	is	$35.
                                                         7
      LMU - DeBusk College of Osteopathic Medicine Health Care Plans for Students


Step Therapy                                                    A Broad Network of Retail Pharmacies
Step	Therapy	is	a	form	of	Prior	Authorization.	When	            BlueCross BlueShield of Tennessee members access
Step Therapy is required, You must initiallytry a drug          the Caremark network for retail pharmacy benefits.
that has been proven effective for most people with             Your pharmacy network provides tremendous
Your condition. This initial drug will be a Covered             accessibility	in	Tennessee	as	well	as	nationally.	A	
Generic	Drug	(if	available)	or	a	Preferred	Brand	Drug.          directory of participating pharmacies is available
                                                                online	at	www.bcbst.com.	Click	on	Find	a	Pharmacy,	
However, if You have already tried an alternate, less
                                                                and enter the pharmacy network code that appears
expensive	drug	and	it	did	not	work,	or	if	Your	doctor	
                                                                in the bottom center of your BlueCross BlueShield of
believes	that	You	must	take	the	more	expensive	drug	
                                                                Tennessee	ID	card.	This	code	will	start	with	RX	(RX04,	
because of Your medical condition, Your doctor can
                                                                for	example).
contact	the	Plan	to	request	an	exception.	If	the	request	
is approved, the Plan will cover the requested drug.            Self-Administered Specialty Pharmacy Network
                                                                and Coverage
Refills
                                                                You have a separate network for Specialty Drugs: the
Refills must be dispensed pursuant to a Prescription.
                                                                Specialty Pharmacy Network. You receive the highest
If the number of refills is not specified in the
                                                                level of benefits when you use a Specialty Pharmacy
Prescription, benefits for refills will not be provided
                                                                Network provider for your selfadministered Specialty
beyond one year from the date of the original
                                                                Drugs. Accredo Health Group, Caremark Specialty
prescription.
                                                                Pharmacy Services, CuraScript, Inc., and Walgreens
The Plan has time limits on how soon a Prescription             Specialty Pharmacy	are	experienced	in	managing	
can be refilled. If you request a refill too soon,              high-cost drugs and providing patient support for
the Network Pharmacy will advise you when your                  complex	conditions	such	as	Hepatitis	C,	Multiple	
Prescription benefit will cover the refill.                     Sclerosis,	Arthritis	and	Hemophilia.

Prescription Home Delivery                                                                   Caremark Specialty
Enjoy the convenience of prescription home delivery.            Accredo Health Group         Pharmacy Services
Simply mail a completed form along with the written             1-888-239-0725	(phone)       1-800-237-2767	(phone)
prescription and payment in one of the envelopes                1-866-387-1003	(fax)         1-800-323-2445	(fax)
provided or visit the pharmacy section at bcbst.com
for other helpful ways to have your prescriptions
                                                                                             Walgreens Specialty
delivered to your home or another preferred address.
                                                                CuraScript, Inc.             Pharmacy
Home Delivery Retail Network                                    1-888-773-7376	(phone)       1-888-347-3416	(phone)
Another	convenient	way	to	obtain	up	to	a	90-calendar-           1-888-773-7386	(fax)         1-877-231-8302	(fax)
day supply of drugs is through the Home Delivery                You may purchase self-administered Specialty Drugs
Retail network. The Home Delivery Retail Network is             from a retail pharmacy, but your copay will be higher.
a network of retail pharmacies that are permitted to            When purchasing self-administered Specialty Drugs
dispense prescription drugs to BlueCross BlueShield of          from an Out-of-Network Pharmacy, you must pay all
Tennessee members on the same terms as pharmacies               expenses	and	file	a	claim	for	reimbursement	with	
in	the	Home	Delivery	Network.	A	directory	of	the	               us.	You	will	be	reimbursed	based	on	the	Maximum	
participating Home Delivery Retail Network is available         Allowable	Charge,	less	any	applicable	Drug	
online at bcbst.com.                                            Copayment amount.

Out-of-Network Pharmacies                                       Please refer to the Specialty Drug List to see which
                                                                drugs are covered as self-administered specialty
If a prescription is filled at an out-of-network
                                                                Drugs.	Go	to	bcbst.com/Pharmacy.
pharmacy,	you	must	pay	all	costs.	A	claim	can	then	
be submitted to BlueCross BlueShield of Tennessee.              Special	Pharmacy	Products	are	limited	to	a	30-day	
Reimbursement is based on the BlueCross BlueShield              supply per prescription.
of Tennessee allowed charge, less any applicable
copay, deductible or coinsurance amount.
                                                            8
      LMU - DeBusk College of Osteopathic Medicine Health Care Plans for Students


Self-Administered Specialty Pharmacy Products
                              Specialty Pharmacy               Other Network            Out-of-Network
                                    Network                      Pharmacies                Pharmacies
 A	Self-Administered        $100	Drug	Copayment	          $200	Drug	Copayment	     You pay all costs,
 Specialty Pharmacy         per prescription              per prescription         then file a claim for
 Product, as indicated on                                                          reimbursement. You
 our Specialty Pharmacy                                                            will be reimbursed
 Products list.                                                                    based	on	the	Maximum	
                                                                                   Allowable	Charge,	less	
                                                                                   any applicable Drug
                                                                                   Copayment amount.

                      If a drug that is on our Specialty Pharmacy Products list is also a
                   Generic Drug or a Preferred Brand Drug, then Your Copayment will be:
 A	Generic Drug that is       $20	Drug	Copayment	per	 $40	Drug	Copayment	           You pay all costs,
 also a Self-Administered prescription                   per prescription           then file a claim for
 Specialty Pharmacy                                                                 reimbursement. You
 Product, as indicated on                                                           will be reimbursed
 our Specialty Pharmacy                                                             based	on	the	Maximum	
 Products list.                                                                     Allowable	Charge,	less	
                                                                                    any applicable Drug
                                                                                    Copayment amount.
 A	Preferred Brand Drug $70	Drug	Copayment	              $140	Drug	Copayment	       You pay all costs,
 that is also a Self-         per prescription           per prescription           then file a claim for
 Administered Specialty                                                             reimbursement. You
 Pharmacy Product, as                                                               will be reimbursed
 indicated on our Specialty                                                         based	on	the	Maximum	
 Pharmacy Products list.                                                            Allowable	Charge,	less	
                                                                                    any applicable Drug
                                                                                    Copayment amount.


(Please refer to Your EOC for information on benefits for provider-administered Specialty Pharmacy Products,
which	are	covered	as	a	Medical	benefit.)

Need More Information?
For	more	information	on	prescription	drug	coverage	or	our	pharmacy	programs	call	1-800-565-9140.	
You can also visit the pharmacy section at bcbst.com.




                                                      9
       LMU - DeBusk College of Osteopathic Medicine Health Care Plans for Students


Benefits will not be provided for:                                        stolen,	or	misplaced	medications	(except	as	required	by	
                                                                          applicable	law);
•	 drugs for the treatment of onychomycosis (e.g.,
   nail	fungus),	except	for:	1)	diabetics;	or	2)	immuno-                •	 drugs	dispensed	by	a	Provider	other	than	a	Pharmacy;
   compromised patients.                                                •	 administration	or	injection	of	any	drugs;
•	 growth	hormones,	except	for:	1)	treatment	of	absolute	               •	 Prescription	Drugs	used	for	the	treatment	of	infertility;
   growth hormone deficiency in children whose epiphyses
   have	not	closed;	2)	patients	with	“Turner’’	syndrome;	               •	 Prescription	Drugs	not	on	the	Drug	Formulary;
   and	3)	patients	with	Prader-Willi	syndrome	confirmed	by	             •	 anorectics (any drug or medicine for the purpose of
   appropriate	genetic	testing;                                            weight	loss	and	appetite	suppression);
•	 prescription and non-prescription medical supplies,                  •	 nicotine replacement therapy and aids to smoking
   devices	and	appliances,	except	for	syringes	used	                       cessation	including,	but	not	limited	to,	patches;
   in conjunction with injectable medications or other
                                                                        •	 all	newly	FDA	approved	drugs	prior	to	review	by	
   supplies	used	in	the	treatment	of	diabetes	and/or	
                                                                           the	Plan’s	P	&	T	Committee.	Prescription	Drugs	that	
   asthma;
                                                                           represent an advance over available therapy according
•	 immunizations or immunological agents, including but                    to	the	P	&	T	Committee	will	be	reviewed	within	at	least	
   not	limited	to:	1)	biological	sera,	2)	blood,	3)	blood	                 six	(6)	months	after	FDA	approval.	Prescription	Drugs	
   plasma;	or	4)	other	blood	products	are	not	Covered,	                    that appear to have therapeutic qualities similar to those
   except	for	blood	products	required	by	hemophiliacs.                     of an already marketed drug, will be reviewed within at
•	 injectable	drugs,	unless:	1)	intended	for	                              least	twelve	(12)	months	after	FDA	approval;
   selfadministration;	or	2)	defined	by	the	Plan.                       •	 any Prescription Drugs or medications used for the
•	 drugs which are prescribed, dispensed or intended for                   treatment	of	sexual	dysfunction,	including	but	not	
   use while You are confined in a hospital, skilled nursing               limited	to	erectile	dysfunction	(e.g.	Viagra),	delayed	
   facility	or	similar	facility,	except	as	otherwise	Covered	in	           ejaculation,	anorgasmia	and	decreased	libido;
   the	EOC;                                                             •	 Prescription Drugs used for cosmetic purposes
•	 any drugs, medications, Prescription devices or vitamins,               including,	but	not	limited	to:	1)	drugs	used	to	reduce	
   available over-the-counter that do not require a                        wrinkles	(e.g.	Renova);	2)	drugs	to	promote	hair-growth;	
   Prescription	by	Federal	or	State	law;	except	as	otherwise	              3)	drugs	used	to	control	perspiration;	4)	drugs	to	remove	
   Covered	in	the	EOC;                                                     hair	(e.g.	Vaniqa);	and	5)	fade	cream	products;

•	 any	quantity	of	Prescription	Drugs	which	exceeds	that	               •	 any Prescription Drug for which there is an over-the-
   specified	by	the	Plan’s	P	&	T	Committee;                                counter	(OTC)	equivalent	in	both	dosage	and	strength,	
                                                                           except	for	insulin;
•	 any Prescription Drug purchased outside the United
   States,	except	those	authorized	by	Us;                               •	 FDA	approved	drugs	used	for	purposes	other	than	those	
                                                                           approved	by	the	FDA	unless	the	drug	is	recognized	for	
•	 any Prescription dispensed by or through a nonretail                    the treatment of the particular indication in one of the
   internet	Pharmacy;                                                      standard	reference	compendia;
•	 contraceptives which require administration or insertion   •	 Compound drugs filled or refilled at an Out-of-Network
   by a Provider (e.g., non-drug devices, implantable            Pharmacy;
   products	such	as	Norplant,	except	injectables),	except	as	
   otherwise	Covered	in	the	EOC;                              •	 drugs	used	to	enhance	athletic	performance;

•	 medications intended to terminate a pregnancy (e.g.,       •	 Experimental	and/or	Investigational	Drugs;
   RU-486);                                                             •	 Provider-administered Specialty Drugs, as indicated on
•	 non-medical supplies or substances, including support                   Our	Specialty	Drug	list;	and
   garments,	regardless	of	their	intended	use;                          •	 Prescription Drugs or refills dispensed:
•	 artificial	appliances;                                                  ○ in	quantities	in	excess	of	amounts	specified	in	the	
•	 allergen	extracts;                                                        BENEFIT	PAYMENT	section;

•	 any drugs or medicines dispensed more than one year                     ○ without	Our	Prior	Authorization	when	required;	or
   following	the	date	of	the	Prescription;                                 ○ which	exceed	any	applicable	Annual	Maximum	
•	 Prescription Drugs You are entitled to receive without                    Benefit,	or	any	other	maximum	benefit	amounts	
   charge in accordance with any worker’s compensation                       stated in this Rider or the EOC
   laws	or	any	municipal,	state,	or	federal	program;
•	 replacement Prescriptions resulting from lost, spilled,

                                                                   10
      LMU - DeBusk College of Osteopathic Medicine Health Care Plans for Students


Extended Well Care
To maintain your health throughout your life, you
should receive the proper tests and immunizations
at the appropriate time and frequency. Many factors,
including your age, gender, family history and other
special needs, determine when particular services are
beneficial. Therefore you should discuss with your
physician what is right for you.
You and each eligible dependent (age 6 and older)
may receive preventive health services, not to
exceed $300, per calendar year.*	All	services	
must be medically necessary and appropriate and
recommended by the U.S. Preventive Health Task
Force,	or	in	conjunction	with	the	plan’s	preventive	
health care guidelines.
All	well	care	benefits	listed	are	subject	to	the	terms,	
conditions,	limitations	and	exclusions	contained	in	the	
Group	Agreement	and	the	Evidence	of	Coverage.	All
services covered by the Wellcare Rider are subject
to normal contract benefits, which are determined
by type of service and place of service.*
The following is a list of items that are covered as a
part	of	the	annual	preventive	health	exam	for	persons	
age	6	and	older:
•	 Annual	Health	Assessment
•	 Childhood	immunizations
•	 Blood	pressure	screening
•	 Periodic	cholesterol	screening
•	 Periodic	colorectal	cancer	screening,	not	subject	to	
   the	$300	calendar	year	limit*                              *Important Note Regarding Colonoscopy and
•	 Flu	shot                                                   Sigmoidoscopy Benefits:
•	 Tetanus-diphtheria	(Td)	booster                            All	services	covered	by	the	Wellcare	Rider	are	subject	
•	 Pneumoccocal	immunization                                  to normal contract benefits, which are determined by
	•	Other	recommended	adult	immunizations	and	                 type of service and place of service. When Wellcare
   immunizations not completed in childhood                   Rider services are provided in a physician’s office,
•	 Immunizations	for	travel	to	foreign	countries              as the majority are, the office visit benefit applies.
•	 Other	prescribed	x-ray	and	lab	screenings	                 However, colonoscopy and sigmoidoscopy are
   associated with preventive care                            invasive diagnostic surgical procedures, so surgery
•	 Vision	and	hearing	screenings	performed	by	the	            benefits apply to these services. Sigmoidoscopies and
   physician	during	the	preventive	health	exam                colonoscopies performed in the physician’s office
                                                              are subject to the office surgery benefit (copay or
Most of these services are not needed every year, or          deductible/coinsurance,	depending	on	the	benefit	
may be appropriate only for people of particular age          plan).	Sigmoidoscopies and colonoscopies performed
groups, genders, or those who meet other specific             in an outpatient facility are subject to the outpatient
health criteria.                                              surgery benefit	(usually	deductible/coinsurance).




                                                         11
Use Well+Wise® Health Tools and Programs for
Your Better Health
Well+Wise provides healthy solutions for you and
your family. It brings together wellness-related
services, programs and resources from across
BlueCross BlueShield of Tennessee, helping you
make positive steps toward better health and
more informed choices about health care quality
and spending. Best of all, Well+Wise works with
you before health risks grow into serious health
problems.
Well+Wise programs and resources include:
•		BluePerks	for	discounted	services	not	covered	by	
   your health plan
•		Personal	Health	Manager	to	help	you	collect	your	
   personal health information in one convenient
   record
•		Personal	Health	Analysis	that	enables	you	to	
   evaluate your current health risks
•		WalkingWorks	to	help	you	start	and	maintain	a	
   regular walking routine, and many others

BluePerks
Exclusively	for	members,	as	part	of	our	Well+Wise	
member	experience,	the	BluePerks	discount	
program	features	savings	of	up	to	50%	on	health-
related products and elective services not typically
covered by health or dental plans when you present
your BlueCross BlueShield of Tennessee member ID            BluePerks Discounts Include:
card.	Visit	bcbst.com	and	select	the	“learn	about”	         •	 Jenny	Craig® weight loss programs
tab	and	choose	“BluePerks”.
                                                            •	 Fitness	memberships
BluePerks Discount Drug Card                                •	 Massage therapy
You	can	save	up	to	20%	on	any	prescription	drug	            •	 Cosmetic services
not covered by your benefit plan with the BluePerks         •	 Vision care items
Discount Drug Card, including antibiotics, blood
pressure medications and more. Even if you don’t            •	 Vitamins
have a pharmacy benefit, you can take advantage of          •	 Diet and supplement advisors
this discount.                                              •	 Spa services
                                                            •	 Personal trainers
                                                            •	 Mind/Body	and	relaxation	therapy
                                                            •	 Yoga and Tai Chi instruction
                                                            •	 Acupuncture
                                                            •	 Holistic	physicians/practitioners
                                                            •	 LASIK	corrective	vision	surgery
                                                            •	 Health magazine subscriptions


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                                                        BlueCross BlueShield of Tennessee
                                                        1	Cameron	Hill	Circle		|		Chattanooga,	TN	37402
                                                        bcbst.com


BlueCross	BlueShield	of	Tennessee,	Inc.,	an	Independent	Licensee	of	the	BlueCross	BlueShield	Association   COMM-659	(6/10)
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