Outline of Coverage

• Lifetime Maximum - Benefit $5,000,000

• Benefit Period—Calendar Year (January 1 through December 31)

• Deductible Waived For—Primary Care Services Benefit (if selected), Diabetic Education, Well-Child Care, Mammograms (up to the first $70)

• Primary Care Services Benefit— the Primary Care Services Benefit covers home and office calls when services are provided by a Participating Professional Provider. Covered services pay at 100% until the Primary Care Services Benefit maximum is reached. Services include: office calls, any services and supplies provided during the office call; Physical examinations; vision examinations; Gynecological examinations, including routine PAP smears; immunizations and vaccinations not covered under the Well-Child Care benefit; Diagnostic x-ray and laboratory services; Services which are provided for the treatment of an accident, if provided in a Participating Professional Provider’s office. After
  your Primary Care Services Benefit limit is reached, your annual deductible and co-insurance apply to covered services.  If Primary Care Services are provided by a nonparticipating
  professional provider, deductible and co-insurance apply.

• Preferred Provider Organization (PPO)—When you receive inpatient or outpatient services from a Healthlink PPO network hospital or surgery center, you receive the most value from your health care benefits while limiting your out-of-pocket expenses.

• Locate Participating Providers and HealthLink PPO hospitals and surgery centers in Montana—visit the BCBSMt website at www.bcbsmt.com or call
  Customer Service at 1-800-447-7828.

• Nationwide networks at your fingertips—With BlueCard, you have access to Participating Providers and PPO providers across the country. visit the BlueCross and BlueShield Association website at www.bcbs.com /healthtravel/ or call 1-800-810-BlUE.

• Balance Billing—out-of-network providers can bill
  you the difference between the allowable fee and
  their total charge, plus any deductible and co-insurance,  potentially making your out-of-pocket expenses significantly higher.

Benefit

Covered Services

Professional Provider Services

Home and office calls, surgery, anesthesia, diagnostic lab and  x-ray, and maternity services. deductible waived for newborn care.

Room and board, special care units, ancillary charges and
transplant coverage.

Accidental injury, x-ray and lab, surgery, chemotherapy, respiratory therapy, radiation therapy, medical emergency, surgery center, blood transfusion services, ambulance, and orthopedic devices. any services provided in an emergency room are not covered under your Primary Care Services Benefit.

Physical, occupational, speech and cardiac rehabilitation therapies. $2,000 maximum per benefit period, combined for outpatient professional and facility charges.

$100,000 lifetime maximum, per member, combined for inpatient and outpatient rehabilitation therapy services.

Not Covered.

Initial purchase, replacements and repair. Prior authorization is recommended if charges are over $500.

Outpatient

Inpatient

Note: Severe Mental Illness is processed under regular medical benefits.

$2,000 maximum per benefit period.

21 days for professional, hospital and/or freestanding inpatient facility charges, per year combined with Chemical Dependency. Inpatient day maximum applies. Plan notification is recommended.

$1,000 per benefit period for outpatient services. 21 days for professional and/or freestanding inpatient facility charges, per member, per benefit period combined with Mental Illness.  $4,000 maximum benefit per benefit period.

$8,000 lifetime maximum benefit.

Well-child exams, lab tests and immunizations through seven years of age.

Paid at 100% of the actual charge, up to a maximum of $70. deductible and coinsurance apply to any balance after the first $70 is paid.

Up to $250 per benefit period for outpatient services.

Generics only. $100 drug deductible, $5 copay, $2500 annual maximum benefit. You may also use your Prescription drug Card to obtain discounted pricing when you purchase non-covered prescriptions.

New West Health Services     Fortis Health Insurance