Benefit Booklet BenefitBooklet for SAMPLE An Independent Licensee of the Blue Cross and Blue Shield Association BENEFIT BOOKLET This benefit booklet, along with the GROUP CONTRACT, is the legal contract between your EMPLOYER and Blue Cross and Blue Shield of North Carolina. Please read this benefit booklet carefully. Blue Cross and Blue Shield of North Carolina agrees to provide benefits to the qualified SUBSCRIBERS and eligible DEPENDENTS who are listed on the enrollment application and who are accepted in accordance with the provisions of the GROUP CONTRACT entered into between Blue Cross and Blue Shield of North Carolina and the SUBSCRIBER’S EMPLOYER. A summary of benefits, conditions, limitations, and exclusions is set forth in this Benefit Booklet for easy reference. Blue Cross and Blue Shield of North Carolina has directed that this Benefit Booklet be issued and signed by the President and the Secretary. Attest: President and Chief Executive Officer Secretary Important Cancellation Information-Please Read The Provision In This Benefit Booklet Entitled,SAMPLE “When Coverage Begins And Ends.” TABLE OF CONTENTS GETTING STARTED WITH BLUE LOCAL WITH ATRIUM HEALTH HSA.........................7 GETTING STARTED.................................................................................................................7 NOTES ON WORDS...................................................................................................................7 THIS BOOKLET.........................................................................................................................7 PRIOR REVIEW AND CERTIFICATION..................................................................................7 EXCLUSIONS AND LIMITATIONS..........................................................................................7 NO ASSIGNMENT OF BENEFITS.............................................................................................7 MORE INFORMATION UPON REQUEST................................................................................8 MEDICAL AND REIMBURSEMENT POLICIES......................................................................8 REDUCED OR WAIVED PAYMENTS......................................................................................8 FOR HELP IN READING THIS BENEFIT BOOKLET..............................................................9 WHO TO CONTACT?.................................................................................................................. 10 TOLL-FREE PHONE NUMBERS, WEBSITE AND ADDRESSES..........................................10 VALUE-ADDED PROGRAMS.................................................................................................11 SUMMARY OF BENEFITS..........................................................................................................12 HOW BLUE LOCAL WITH ATRIUM HEALTH HSA WORKS...............................................13 MOST COST-EFFECTIVE BENEFIT LEVEL..........................................................................13 OUT-OF-NETWORK BENEFIT EXCEPTIONS.......................................................................15 BUNDLED CARE AND PAYMENTS PROGRAM.................................................................. 16 CARRY YOUR ID CARD.........................................................................................................16 THE ROLE OF A PRIMARY CARE PROVIDER (PCP) OR SPECIALIST..............................16 COVERED SERVICES..................................................................................................................18 OFFICE SERVICES..................................................................................................................18 PREVENTIVE CARE............................................................................................................... 19 FEDERALLY-MANDATED PREVENTIVE CARE SERVICES........................................19 STATE-MANDATED PREVENTIVE CARE SERVICES..................................................20 OBESITY TREATMENT/WEIGHT MANAGEMENT.............................................................22 EMERGENCY, URGENT CARE AND AMBULANCE SERVICES.........................................23 EMERGENCY SERVICES.................................................................................................23 WHAT TO DO IN AN EMERGENCY............................................................................... 23 AMBULANCE SERVICES.......................................................................................................24 URGENT CARE.................................................................................................................24 HOSPITAL AND OTHER FACILITY CARE...........................................................................24 ALTERNATIVES TO HOSPITAL STAYS...............................................................................25 HOME HEALTH CARE.....................................................................................................25 HOSPICE SERVICES.........................................................................................................25 SAMPLEPRIVATE DUTY NURSING..............................................................................................25 SG BlueLocal, 5/20 i TABLE OF CONTENTS (cont.) FAMILY PLANNING...............................................................................................................26 MATERNITY CARE..........................................................................................................26 ELECTIVE TERMINATION OF PREGNANCY (ABORTION).........................................27 COMPLICATIONS OF PREGNANCY...............................................................................27 INFERTILITY SERVICES.................................................................................................27 SEXUAL DYSFUNCTION SERVICES..............................................................................27 STERILIZATION...............................................................................................................27 CONTRACEPTIVE DEVICES...........................................................................................28 FAMILY PLANNING EXCLUSIONS................................................................................28 SPECIFIC THERAPIES AND TESTS.......................................................................................28 HOME INFUSION THERAPY SERVICES........................................................................28 REHABILITATIVE THERAPY AND HABILITATIVE SERVICES..................................28 OTHER COVERED THERAPIES......................................................................................29 DIAGNOSTIC SERVICES........................................................................................................29 DIAGNOSTIC SERVICES EXCLUSIONS.........................................................................29 OTHER SERVICES.................................................................................................................. 29 BLOOD...............................................................................................................................29 CERTAIN DRUGS COVERED UNDER YOUR MEDICAL BENEFIT.............................30 CLINICAL TRIALS........................................................................................................... 30 DENTAL TREATMENT COVERED UNDER YOUR MEDICAL BENEFIT....................30 PEDIATRIC DENTAL SERVICES.................................................................................... 32 PEDIATRIC VISION SERVICES.......................................................................................35 TEMPOROMANDIBULAR JOINT (TMJ) SERVICES.............................................................36 DIABETES RELATED SERVICES....................................................................................36 EQUIPMENT AND SUPPLIES.................................................................................................36 DURABLE MEDICAL EQUIPMENT................................................................................36 HEARING AIDS.................................................................................................................36 LYMPHEDEMA-RELATED SERVICES...........................................................................37 MEDICAL SUPPLIES........................................................................................................37 ORTHOTIC DEVICES.......................................................................................................37 PROSTHETIC APPLIANCES.............................................................................................37 SURGICAL BENEFITS............................................................................................................38 ANESTHESIA....................................................................................................................38 TRANSPLANTS.......................................................................................................................39 TRANSPLANTS EXCLUSIONS........................................................................................39 BLUE DISTINCTION® CENTERS....................................................................................39 MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES.................................................40 SAMPLEHOW TO ACCESS MENTAL HEALTH