· 2014-10-22 · your enrollment information student health plan 2014–2015 louisiana state...

www.bcbsla.com

www.bcbsla.com

Your Enrollment InformationStudent Health Plan 2014–2015Louisiana State University Health Sciences Center

01MK4032 R8/14 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and incorporated as Louisiana Health Service & Indemnity Company.

Thank Youfor choosing Blue Cross and Blue Shield of Louisiana.

This document is presented for general information only. It is not a benefit plan, nor intended to be construed as a benefit plan. If there is any discrepancy between this document and the benefit plan, the benefit plan will govern the benefits paid. For complete information, please refer to the benefit plan. Premiums will vary with the amount of benefits chosen. Please refer to benefit plans #40HR1611 07/14 and #40XX1439 07/14 for complete details.

Blue Cross and Blue Shield of Louisiana is proud to serve the healthcare needs of LSUHSC students. Your Blue Cross plan offers many benefits and features, including:

• Alargenetworkofdoctorsandhospitals

• Physicianofficevisits

• Directaccesstospecialtycarewithoutareferral

• Prenatalcare

• Preventiveandwellnessservices

• Pharmacybenefits

• Mentalhealthcounseling

• Substanceabuseservices

• Onlinetoolstohelpyougetthemostfromyourhealthplan

• AnIDcardrecognizedacrosstheglobe

• Localcustomerservice

Please keep this brochure handy for more details on your Blue Cross plan!

1

CUSTOMER SERVICEOnline: www.bcbsla.com

By phone: 1-800-495-BLUE (2583)

In person: 5525 Reitz Avenue Baton Rouge, LA 70809

Or 3501 North Causeway Boulevard Suite 600 Metairie, LA 70002

Service…Our company is committed to meeting the challenging demands of healthcare in the 21st century. As part of this commitment, we constantly strive for excellence in customer service. Our goal is to continuously enhance our portfolio of products to offer the most affordable and comprehensive health insurance plans available in the state.

Blue Cross gives you Coverage when – and where – you need it mostYoucan’tpredictwhenyoumightneedtovisitadoctororpharmacy.That’swhyBlueCrossgivesyouaccesstohealthcareathomeandabroad.

Network BenefitsBlueCrossmembersmayaccessthePreferredCarenetworkofdoctors,hospitalsandalliedhealthcareprofessionals.Networkproviderswillsubmityourclaimsforyou.TofindaBlueCrossdoctororhospitalnearby,visitwww.bcbsla.comandclickonFiNd a doCTor or drUG.

YourStudentHealthCentersofferseveralconvenientcampuslocationswhereyoumayreceivenetworkbenefits,including:

• Physicianofficevisits

• Preventiveandtreatmentoptions

• Pharmacyservices

• Mentalhealthcounseling

• Substanceabuseservices

Care away From HomeIfyou’reoutsideofLouisianaandneedmedicalcare,yourbenefitstravelwithyou.YourBlueCrossplanispartofasingleelectronicnetworklinkingBlueCrossandBlueShieldplansacrossthenation–andinmorethan200countriesandterritoriesworldwide.TolocateadoctororhospitaloutsideofLouisiana,visitwww.bcbsla.com/findcareorcalltheBlueCardAccesslineat1-800-810-BLUE(2583).

2

Student Health Clinics

(8 a.m. to 4:30 p.m., Monday through Friday)3700 St. Charles AvenueNew Orleans, LA 70112504-412-1366

(8 a.m. to 4:30 p.m., Monday through Friday,by appointment only)200 W. Esplanade Avenue Suite 205Kenner, LA 70065504-412-1705

Student Health Services

(8 a.m. to 4:30 p.m., Monday through Friday)7th Floor of the Lions Building2020 Gravier StreetNew Orleans, LA 70112504-525-4839Fax: 866-814-9706

online Health and Wellness Educational ToolsWithMy Health, My Way,youcangettheresourcesyouneedtocommittohealthier,happierliving.

ExploretheMaintain My Healthsectiontofind:

• Wellness Discounts offered through Blue 365–SpecialsavingsforBlueMembersonserviceslike:•Fitnessclubmemberships•Athleticwearandgear•Dietandweight-controlprograms•Laservisioncorrection•Hearingcareandseniorcare

• Wellness Support–Findaschedulethatremindsyouofthepreventivehealthscreeningsyoushouldhaveateveryagetostayontopofyourhealth.Also,explorealistingofeventsandresourcesinyourregion.

ToaccessmoreMyHealth,MyWaybenefits,visitwww.benefitsforbetterliving.com.

activate Your online account!Youcanregisterforanonlineaccountbyvisitingwww.bcbsla.com/activate.

Toregister,youwillneedyourMemberIDnumber(foundonyourMemberIDcard)andasecurePersonalIdentificationNumber(PIN).IfyouhavenotreceivedaPINinthemail,oryouhavelostyours,youcanrequestanewoneatthesecondstepoftheregistrationprocess.

BlueCrossprovidestelephonesupportforuserswhoneedhelpwiththeironlineaccountregistrationprocess,includingholidaysandweekends.Soifyouneedanyhelpregisteringorloggingin,youcancalltoll-free1-800-821-2753anytime.

Rememberthisisonlysupportfortheregistrationprocess.Ifyouneedhelpwithyourbenefitsorclaims,pleasecalltheCustomerServicenumberonyourBlueCrossIDcard.

Our searchable provider directories are

updated each night.

3

networK out-oF-networK

Calendar Year Deductible – Aggregate $0 Individual / $0 Family $1,000 Individual / $3,000 Family

Out-of-Pocket Calendar Year Maximum $2,000 Individual / $4,000 Family Aggregate $4,000 Individual / $8,000 Family (Excludes Deductible)

oFFiCe visits and Preventive Care

Physician Office Visit $25 Copayment per visit Deductible then 70/30 Coinsurance*

Specialist Office Visit $40 Copayment per visit Deductible then 70/30 Coinsurance*

Wellness Visit $0 Copayment per visit – 100% Deductible then 70/30 Coinsurance*

Lab and Low Tech X-ray (Includes Independent Facility) Plan pays 100% Deductible then 70/30 Coinsurance*

High Tech X-ray Services (Includes Independent Facility) Plan pays 100% Deductible then 70/30 Coinsurance*

outPatient serviCes PerFormed at an outPatient FaCility

Facility Charges $300 Copay Deductible then 70/30 Coinsurance*

Professional Services Plan pays 100% Deductible then 70/30 Coinsurance*

Lab and X-ray Plan pays 100% Deductible then 70/30 Coinsurance*

inPatient serviCes (30% non-Participating hospital penalty will also apply)

Hospital $300 per day for the first (3) days of admission Deductible then 70/30 Coinsurance*

Professional Services Plan pays 100% Deductible then 70/30 Coinsurance*

BeneFits that reQuire authoriZation (does not include list of outpatient services or drugs requiring authorization)

Organ and Tissue Transplants Plan pays 100% Not Available

Skilled Nursing Facility Plan pays 100% Deductible then 70/30 Coinsurance*

Home Health Plan pays 100% Deductible then 70/30 Coinsurance*

Hospice Plan pays 100% Deductible then 70/30 Coinsurance*

other Covered serviCes

Prenatal Visits and Delivery $40 Copayment per pregnancy Deductible then 70/30 Coinsurance*

Emergency Room $150 Copayment per visit/ waived if admitted

$150 Copayment per visit/ waived if admitted

Speech Therapy – Excludes Inpatient $25 Copayment per visit Deductible then 70/30 Coinsurance*

Physical/Occupational Therapy – Excludes Inpatient $25 Copayment per visit Deductible then 70/30 Coinsurance*

Urgent Care Center $40 Copayment per visit Deductible then 70/30 Coinsurance*

Ambulance $50 Copayment per day per provider Deductible then 70/30 Coinsurance*

Prosthetic Limbs Plan pays 100% Deductible then 70/30 Coinsurance*

Durable Medical Equipment 80/20 Coinsurance Deductible then 70/30 Coinsurance*

needle stiCK BeneFit

Hepatitis/HIV Antibody/ Antigen Tests and Vaccines 100% 100%

Lab Work 100% 100%

Outpatient Facility Charges 100% 100%

BeneFits at a glanCeBASICBLUEPLAN

All benefits based on allowable charges. *Accrues to the Out-of-Pocket Maximum This is only an outline – all benefits are subject to the terms and conditions of the contract. In the case of a discrepancy, the contract will prevail.

PresCriPtion drug Coverage Therearetwowaystofillyourprescriptions:1.Bringyourprescriptiontoanetworkpharmacyand

payonecopaymenttocoveruptoa30- or 90-daysupply(ormanufacturer’srecommendeddosage);or

2.Formaintenancedrugsandtheconvenienceofmail-orderdelivery,youpayacopaymentequaltothreetimestheretailcopaymentforuptoa90-daysupply(ormanufacturer’srecommendeddosage).

Tier Level Description Retail Copayment Mail-Order (up to 30-day supply) Copayment (up to 90-day supply)

Tier1 Primarilygenericdrugs,althoughsome $7 $21 brand-namedrugsmayfallintothistier

Tier2 Primarilybrand-namedrugs,althoughsome $30 $90 genericdrugsmayfallintothistier

Tier3 Brand-nameorgenericdrugsthatmayhave $70 $210 atherapeuticalternativeasaTier1orTier2 drug;coveredcompoundeddrugsareincluded inthistier

Tier4 Aprescriptiondrugthatisamulti-source 10%specialtywith$100maximum branddrug

Prescription drugs are a regular medical expense

for many people. That is why it is important to have

easily accessible drug benefits. Blue Cross plans provide coverage through

a prescription drug program where members

pay a copayment at the time of purchase.

5

• Network Benefits

• Non-network Benefits

• Hospital Care

• Urgent Care Benefits

• Emergency Care Benefits

• Preventive Care

• Wellness Benefits

• Prescription Drug Program

Benefit OverviewPhysician Office Visit Copayments $25

Specialist Office Visit Copayments $40

Deductible$0/Individual per Calendar Year

$0/Family per Calendar Year

Coinsurance 100% In-network30% Out-of-network

Out-of-Pocket Maximum $2,000 Individual$4,000 Family

Prescription Drug Copayments $7/$30/$70/10% Specialty with $100 max

Emergency Room Copayment $150

Urgent Care Copayment $40

Ambulance Copayment $50

6

mental health and suBstanCe aBuse serviCesCoverageforMentalHealthandSubstanceAbuseCareispaidthesameas,orbetterthananyotherillness.

Mental Health Counseling•EmotionalDifficulties

• Stress

• SubstanceAbuse

7

Age Band

Member Rate*

Age Band

Member Rate*

0-20 $151.17 43 $323.05

21 $238.06 44 $332.57

22 $238.06 45 $343.76

23 $238.06 46 $357.09

24 $238.06 47 $372.08

25 $239.01 48 $389.23

26 $243.77 49 $406.13

27 $249.49 50 $425.17

28 $258.77 51 $443.98

29 $266.39 52 $464.69

30 $270.20 53 $485.64

31 $275.91 54 $508.25

32 $281.62 55 $530.87

33 $285.19 56 $555.39

34 $289.00 57 $580.15

35 $290.91 58 $606.57

36 $292.81 59 $619.67

37 $294.72 60 $646.09

38 $296.62 61 $668.94

39 $300.43 62 $683.94

40 $304.24 63 $702.75

41 $309.95 64 $714.17

42 $315.43 65-999 $714.17

*Rates by Contract Holder: Rates by contract

will be established for each member covered under the contract in accordance with

the Age Bands at left. For dependent members under the age of 21, each

member will be rated independently up to a

maximum of three minor dependents per contract.

For dependents age 21 and over, each dependent will

be rated independently without any maximum number of dependents.

CopaymentsAcopaymentisafixeddollaramountthatyoupayforacoveredserviceorprescriptiondrug.Copaymentsareavailableformostservicesinthenetwork.Thesecopaymentamountsaredetailedthroughoutthisbookletandinyourbenefitplan.

deductibles and CoinsuranceAbenefitperiodisdefinedasacalendaryear:January 1 throughDecember31.Fornewmembers,yourbenefitperiodbeginsonyoureffectivedateofcoverageandendsonDecember31.

Onceyourdeductibleismet,youpayacoinsurance,whichmeansyourcostsaresharedwithBlueCross.Onceyouhavereachedyourannualout-of-pocketmaximum,BlueCrosswillpay100percentoftheallowablechargesforyourcoveredbenefits.Pleaseseeyourbenefitplanforspecificdetailsonyourdeductible,coinsurancepercentageandannualmaximums.

out-of-Network BenefitsIfyoureceivecareoutsideofthePreferredCarePPOnetwork,youwillfirsthavetomeetthe$1,000out-of-networkdeductible($3,000forfamilies),thenpayapercentageoftheremainingbalanceformostservices.

Urgent Care BenefitsTheremaybeinstanceswhenyouneednon-emergencymedicalcareafterhours.Thisisreferredtoas“urgentcare.”Examplesofurgentcareinclude,butarenotlimitedto:coldsandflu,sprains,stomachachesandnausea.Urgentcarecentersofferextendedofficehourstopatientsonanunscheduledbasiswithouttheneedforanappointment.

8

This innovative coverage features a

comprehensive network with

the affordability and predictability

of copayments.

Emergency Care BenefitsAsalways,inemergencysituationsthefirstpriorityistoseektreatmentatthenearestfacility.Pleasecallyourphysicianwithin48hoursafterseekingemergencytreatment.Authorizationforanemergencyinpatientadmissionmustberequestedwithin48hoursofhospitaladmission.

Preventive and wellness Care*ThePatientProtectionandAffordableCareActisbringingchangestothehealthcareindustry.Weareworkinghardonbehalfofourmemberstoimplementhealthcarereformprovisionsasregulationsaredefined.Thelistbelowisasampleofpreventiveservicesavailabletoourcustomersandtheirenrolleddependentsatnoout-of-pocketcostwhenobtainedfromanetworkprovider.

Network Care:• $0copaymentforoneroutinephysicalexam

• Routinegynecologicalexams

• Papsmear

• Routinemammographyexam,iforderedbyaphysician

• well-babycarefordependentchildren

• Immunizationsrecommendedbyaphysician

• Prostate(PSA)screeningtest

• Routinehemoccult(colon)testforadultmenandwomen

• Labandlow-techX-rayservicescoveredat100percent

• Visionimpairmentscreening

*Subjecttoagerequirementlimitsforcertainpreventiveservices.9

Blue Cross is committed to preventive care.

Detecting illnesses in their earliest stages

ensures better health for our members and reduces medical costs

for everyone. To promote preventive care, Blue Cross

plans cover a full array of wellness services.

other serviCes and CareSomeservicesrequirepriorauthorization.CheckyourScheduleofBenefitsforalistoftheseservices.

Prenatal Care (Visits and delivery)• In-Network:$40copaymentperpregnancy• Out-of-Network:deductible,then70/30coinsurance

Emergency room• In-Network:$150copaymentpervisit

(waivedifadmittedtohospital)• Out-of-Network:$150 copaymentpervisit

(waivedifadmittedtohospital)

Urgent Care Centers• In-Network:$40copaymentpervisit• Out-of-Network:deductible,then70/30coinsurance

ambulance Services• In-Network:$50 copaymentperdayperprovider• Out-of-Network:deductible,then70/30coinsurance

outpatient Services(includesfacilitycharges,professionalservices,labandX-rayservicesperformedatanoutpatientfacility)

• In-Network:planpays100%• Out-of-Network:deductible,then70/30coinsurance

inpatient Services(separatechargesforhospitalandprofessionalservices;30%Non-ParticipatingHospitalpenaltywillalsoapply)

• In-Network:$300 perday•Out-of-Network:deductible,then70/30coinsurance

10

Speech Therapy •In-Network:$25copaymentpervisit•Out-of-Network:deductible,then70/30coinsurance

Physical/occupational Therapy • In-Network:$25copaymentpervisit• Out-of-Network:deductible,then70/30coinsurance

Prosthetic Limbs • In-Network:planpays100%• Out-of-Network:deductible,then70/30coinsurance

durable Medical Equipment • In-Network:80/20coinsurance• Out-of-Network:deductible,then70/30coinsurance

Home Health Services• In-Network:planpays100%• Out-of-Network:deductible,then70/30coinsurance

Hospice Care• In-Network:planpays100%• Out-of-Network:deductible,then70/30coinsurance

organ and Tissue Transplants• In-Network:planpays100%• Out-of-Network:nobenefitsavailable

Skilled Nursing Facility• In-Network:planpays100%• Out-of-Network:deductible,then70/30coinsurance

11

12

needle stiCK BeneFitNeedlestickinjuriesthatexposestudentstoblood-bornepathogensareanimportantpublichealthconcern.That’swhyBlueCrossoffersaseparateNeedleStickbenefit,whichisavailableontheBasicBluePlanorasastand-aloneoption.Thisbenefitprovidescoverageforeligiblestudentsfortestingandprophylactictreatmentofblood-bornediseasesfollowingat-riskcontactwithbloodorotherbodilyfluidsfromhumanoranimalsources.Thecontactmayinclude,butisnotlimitedto,needlesticks.Thisbenefitisnotsubjecttoanycopaymentorannualdeductiblerequirement.Pleaseseeyourbenefitplanfordetails,limitationsandexclusions.

MembersmayreceivetreatmentbyanyPreferredCarePPOprovider.Tofindaparticipatingdoctororhospital,visitwww.bcbsla.comandclickonFiNd a doCTor or drUG.

13

general ConditionsEligibilityAllregisteredstudents,residents,fellowsandpost-doctoralfellowsareeligiblefortheseBlueCrossplans.InternationalanddomesticstudentsmustpurchasetheBasicBluePlanorprovideproofofcomparablecoveragetotheLSUHealthSciencesCenter.Residents,fellowsandpost-doctoralfellowsmaypurchasetheplanonavoluntarybasis.Onlinestudentsordistance-learningstudentsenrolledinhomestudy,correspondenceortelevisioncoursesarenoteligibletoenrollintheplan.Coveragewillbecomeinvalidforstudentswholeaveschoolwithin31daysoftheireffectivedateofcoverage.Theservicingagentshouldbenotifiedatthattimebythestudent.Studentswhoenrollintheplanmaysecurefamilycoverage.Eligibledependentsmustenrollintheplanwhenthestudentfirstenrollsintheplan,andmustenrollforthesamecoverageasthestudent.

Newbornchildrenwillbecoveredatbirthuntil31daysofageoruntildeemedwellenoughtobedischargedfromthehospital,iftheplanadministratorisnotifiedwithin30daysofbirthandreceivesthecorrectpremiumamount.

Enrollment PeriodFull-timedomesticandinternationalstudentsmustprovideproofofcomparablecoverageorpurchaseaninsuranceplanofferedthroughLSUHSCwithin30daysoftheeffectivedateofcoveragefortheirparticularcollege/program.Allotherstudentsanddependentsmustsubmitacompletedenrollmentformandtheproperpremiumtotheservicingagentwithin30daysoftheeffectivedateofcoveragefortheirparticularcollege/program.Ifenrollmentdoesnotoccurwithintheperiodsspecified,studentsandeligibledependentswillonlybepermittedtoenrollwithin31daysofinvoluntarylossofcoverageunderanotherinsuranceplan,marriageorbirthoradoptionofchild.

Effective and Expiration datesCoveragebecomeseffectiveonthelaterof:12:01a.m.ontheeffectivedateofeachcoverageperiod;thefirstdayofthetermforwhichtheproperpremiumispaid;or12:01a.m.followingthedatetheenvelopecontainingthecompletedenrollmentformandproperpremiumfortheperiodofcoverageispostmarkedbytheU.S.PostalService.Coverageexpiresontheexpirationdateforeachcoverageperiodorwhenpaymentisdueandunpaid.

14

15

College/Program Effective date Expiration date

AlliedHealth 07-01-14 06-30-15SchoolofDentistry 07-01-14 06-30-15GraduateStudies 07-01-14 06-30-15SchoolofMedicine 07-01-14 06-30-15SchoolofNursing 07-01-14 06-30-15Resident/PostGrads 07-01-14 06-30-15SchoolofPublicHealth 07-01-14 06-30-15







Fall

Spring

annual Coverage Periods

Semi-annual Coverage Periods

Summer-only Coverage Periods

College/Programs Coverage Periods

16

to aPPly For Coverage For your eligiBle dePendents:Ifyouareaneligiblestudent,youmayenrollyourdependentsbycompletingtheenrollmentform.MakethecheckpayabletoBlueCrossandBlueShieldofLouisianaandreturnbothto:

GallagherBenefitServices,Inc.ATTN:CassidyMaumusASubsidiaryofArthurJ.Gallagher111VeteransBlvdSuite1130Metairie,LA70005

QuestionsregardingthereceiptofpremiumorverificationofcoverageunderthisinsuranceplanmaybeansweredbycontactingGallagherBenefitat504-378-4637or1-800-605-6102ext.278.

Thisdocumentispresentedforgeneralinformationonly.Itisnotabenefitplan,norintendedtobeconstruedasabenefitplan.Ifthereisanydiscrepancybetweenthisdocumentandthebenefitplan,thebenefitplanwillgovernthebenefitspaid.Forcompleteinformation,pleaserefertothebenefitplan.Premiumswillvarywiththeamountofbenefitschosen.

· 2014-10-22 · your enrollment information student health plan 2014–2015 louisiana state...

Documents