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stages of the mastectomy, including lymphedemas. Children under the age of 16
are covered for physical examinations and age-appropriate immunizations.
Professional services which are furnished by a non-PPO provider are payable at
the non-PPO physician level, and are subject to separate out-of-network co-payment
and expense limitation requirements. Dental services, hospice care
services, mental illness or substance abuse services and organ and tissue
transplant services are not included as professional services, except as
specifically provided under items No. 11, 16, 17 or 18 below.
3. Second surgical opinion. If surgery has been recommended, you may be
required by us to obtain a second opinion. If so, any deductible or co-payment
for the second opinion will be waived.
4. Outpatient prescription drugs and medicines. Covered drugs and medicines,
except drugs used for cosmetic purposes, purchased for your use as an
outpatient from a participating pharmacy using the Plan’s Prescription Drug Card
Program, and which require by federal law a prescription written by a physician.
Insulin and insulin syringes are also covered, even though a prescription may not
be required by law. There are no benefits for any prescriptions purchased from
non-participating pharmacies or for any claims for prescription drugs that are not
filed electronically using the Plan’s Prescription Drug Card Program.
Prescription drug benefits are provided only through a separate prescription drug
card program in lieu of any major medical prescription drug benefits. With this
prescription drug card program, participants pay a separate prescription drug
card co-pay of 20% per prescription of the cost of any covered generic and
branded prescriptions, subject to certain minimums, maximums and other
limitations. Participants do not have to satisfy any deductible in order to receive
benefits under this prescription drug card program.
The 20% co-pay per prescription requirement for this prescription drug card
program is applicable to all covered outpatient prescription drugs, whether
purchased through a retail participating pharmacy or a mail participating
pharmacy. Benefits for each retail prescription are limited to a 30 consecutive
day supply of that drug. Benefits for each mail service prescription are limited to
a 90 consecutive day supply of that drug. The minimum co-pay charged by the
Plan is $5 per prescription for up to a 30 day supply and $10 per prescription for
between a 31 day supply and a 90 day supply. The maximum co-pay charged by
the Plan is $100 per prescription for up to a 30 day supply and $200 per
prescription for between a 31 day supply and a 90 day supply. There is no out-of-
pocket maximum or stop-loss limit on the co-pays for these prescription drug
card program benefits.
The prescription drug card co-pays are based upon the discounted charges
negotiated by the Administrator, Blue Cross Blue Shield of Illinois. The
prescription drug card co-pays do not apply toward the participant’s major
medical deductible or out-of-pocket expense amount. Any benefits that are paid
under this prescription drug card program will be applied to the participant’s
combined medical and drug lifetime maximum benefit of $1,000,000.
5. Use of radium or other radioactive materials. Lower benefits will apply if a
non-PPO provider is used.
