Choice 750 Gold + Family Dental SAMPLE INTRODUCTION Welcome Thank You for Choosing Premera Blue Cross (Premera) for Your Healthcare Coverage
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SAMPLE Choice 750 Gold + Family Dental SAMPLE INTRODUCTION Welcome Thank you for choosing Premera Blue Cross (Premera) for your healthcare coverage. This benefit booklet tells you about your plan benefits and how to make the most of them. Please read this benefit booklet to find out how your healthcare plan works. Some words have special meanings under this plan. Please see Definitions at the end of this booklet. In this booklet, the words "we," "us," and "our" mean Premera. The words "you" and "your" mean any member enrolled in the plan. The word "plan" means your healthcare plan with us. Please contact Customer Service if you have any questions about this plan. We are happy to answer your questions and hear any of your comments. On our website at premera.com you can also: • Learn more about your plan • Find a healthcare provider near you • Look for information about many health topics We look forward to serving you and your family. Thank you again for choosing Premera. This benefit booklet is for members enrolled in this plan. This benefit booklet describes the benefits and other terms of this plan. It replaces any other benefit booklet you may have received. We know that healthcare plans can be hard to understand and use. We hope this benefit booklet helps you understand how to get the most from your benefits. The benefits and provisions described in this plan are subject to the terms of the master group contract (contract) issued to the employer. The employer is the firm, corporation or partnership that contracts with us. This benefit booklet is a part of the contract on file at the employer's office. Medical and payment policies we use in administration of this plan are available at premera.com. This plan will comply with the federal health care reform law, called the Affordable Care Act (see Definitions), including any applicable requirements for distribution of any medical loss ratio rebates and actuarial value requirements. If Congress, federal or state regulators, or the courts make further changes or clarifications regarding the Affordable Care Act and its implementing regulations, including changes which become effective on the beginning of the calendar year, this plan will comply with them even if they are not stated in this booklet or if they conflict with statements made in this booklet. Translation Services If you need an interpreter to help with verbal translation services, please call us. Customer Service will be able to guide you through the service. The phone number is shown on the back cover of your booklet. Group Name: SAMPLE Effective Date: SAMPLE Group Number: SAMPLE Plan: Premera Blue Cross Choice 750 Gold + Family Dental Certificate Form Number: 49831WA196 (01-2021) 49831WA196 (01-2021) 49831WA196 (01-2021) HOW TO USE THIS BENEFIT BOOKLET Every section in this benefit booklet has important information. You may find that the sections below are especially useful. • How to Contact Us – Our website, phone numbers, mailing addresses and other contact information are on the back cover. • Summary of Your Costs – Lists your costs for covered services. • Important Plan Information – Describes deductibles, copays, coinsurance, out-of-pocket maximums and allowed amounts • How Providers Affect Your Costs – How using an in-network provider affects your benefits and lowers your out-of-pocket costs • Prior Authorization – Describes our authorization and emergency admission notifications provision • Clinical Review – Describes our clinical review provision • Personal Health Support Programs – Describes our health support programs • Continuity of Care – Describes how to continue care at the in-network level of benefits when a provider is no longer in the network • Covered Services –A detailed description of what is covered • Exclusions – Describes services that are not covered • Other Coverage – Describes how benefits are paid when you have other coverage and what you must do when a third party is responsible for an injury or illness • Sending Us a Claim –Instructions on how to send in a claim • Complaints and Appeals – What to do if you want to file a complaint or an appeal • Eligibility and Enrollment – Describes who can be covered • Termination of Coverage – Describes when coverage ends • Continuation of Coverage – Describes how you can continue coverage after your group plan ends • Other Plan Information – Lists general information about how this plan is administered and required state and federal notices • Definitions – Meanings of words and terms used 49831WA196 (01-2021) TABLE OF CONTENTS SUMMARY OF YOUR COSTS ..................................................................................................................... 1 IMPORTANT PLAN INFORMATION .......................................................................................................... 10 Calendar Year Deductible ..................................................................................................................... 10 Copays .................................................................................................................................................. 11 Coinsurance .......................................................................................................................................... 11 Out-of-Pocket Maximum ....................................................................................................................... 11 Allowed Amount .................................................................................................................................... 11 HOW PROVIDERS AFFECT YOUR COSTS ............................................................................................. 13 Medical Services ................................................................................................................................... 13 Surprise Billing Protection ..................................................................................................................... 13 Dental Services ..................................................................................................................................... 14 CARE MANAGEMENT ............................................................................................................................... 15 Prior Authorization ................................................................................................................................. 15 Clinical Review ...................................................................................................................................... 17 Personal Health Support Programs ...................................................................................................... 17 Continuity of Care ................................................................................................................................. 17 COVERED SERVICES ................................................................................................................................ 18 Common Medical Services ................................................................................................................... 18 Other Covered Services ........................................................................................................................ 47 WELLNESS-BASED PROGRAMS ............................................................................................................. 51 EXCLUSIONS ............................................................................................................................................. 51 OTHER COVERAGE................................................................................................................................... 55 Coordinating Benefits With Other Plans ............................................................................................... 55 Third Party Liability (Subrogation) ......................................................................................................... 57 SENDING US A CLAIM .............................................................................................................................. 58 COMPLAINTS AND APPEALS .................................................................................................................. 60 ELIGIBILITY AND ENROLLMENT ............................................................................................................. 62 Enrollment in the Plan ........................................................................................................................... 63 Special Enrollment ................................................................................................................................ 64 Open Enrollment ................................................................................................................................... 65 Changes in Coverage ........................................................................................................................... 65 Plan Transfers ....................................................................................................................................... 65 TERMINATION OF COVERAGE ................................................................................................................ 65 Events that End Coverage .................................................................................................................... 65 Contract Termination