Page 10 - 2015 Advia CU Benefits & Notices
P. 10
Advia CU - MI 2015
Patient Protection Notice
The Advia CU HMO Group Health Plans through Blue Care Network of Michigan (BCN) require the
designation of a primary care provider. You have the right to designate any primary care provider who
participates in our network and who is available to accept you or your family members. Until you make
this designation, BCN designates one for you. For information on how to select a primary care provider,
and for a list of the participating primary care providers, contact the BCN at www.bcbsm.com or call
800.662.6667.
For children, you may designate a participating pediatrician as the primary care provider.
You do not need prior authorization from BCN or from any other person (including a primary care
provider) in order to obtain access to obstetrical or gynecological care from a health care professional in
our network who specializes in obstetrics or gynecology. The health care professional, however, may be
required to comply with certain procedures, including obtaining prior authorization for certain services,
following a pre-approved treatment plan, or procedures for making referrals. For a list of participating
health care professionals who specialize in obstetrics or gynecology, contact the BCN website at
www.bcbsm.com and call 800.662.6667.
Waiver of Medical Coverage – Opt Out Option
You may elect to waive medical coverage from Advia CU if you have and
can provide proof of existing coverage from another source (spouse,
parent, etc.). When proof of coverage is provided to Human Resources and
validated, you will be eligible to receive the Opt-Out Option amount in each
pay.
The Opt Out amount is $2,400 for the year, and is paid out in 26 equal
amounts, $92.31 in each pay period.
Should you require to be added to Advia CU’s medical plan, the opt out
amount will cease when medical coverage begins.
Summary of Benefits & Coverage (SBC)
In accordance with the changes mandated by federal health care reform effective the first plan year
following 09/23/2012, your Summary of Benefits & Coverage (SBC) for our medical plans are enclosed.
The purpose of the SBC is to provide an explanation of your medical and prescription benefits (if any) in
an easy to read format. The SBC should look the same for any health plan from any employer since the
format, developed by the federal Department of Labor (DOL), is mandatory.
The SBC should be used in conjunction with the benefit table in the Medical Coverage section of this
booklet and the benefit guide found in the Member Section of the carrier’s website, on your Employee
Home Page on SAM or by clicking HERE.
Salus Group© Copyright 2014 Page | 10
Patient Protection Notice
The Advia CU HMO Group Health Plans through Blue Care Network of Michigan (BCN) require the
designation of a primary care provider. You have the right to designate any primary care provider who
participates in our network and who is available to accept you or your family members. Until you make
this designation, BCN designates one for you. For information on how to select a primary care provider,
and for a list of the participating primary care providers, contact the BCN at www.bcbsm.com or call
800.662.6667.
For children, you may designate a participating pediatrician as the primary care provider.
You do not need prior authorization from BCN or from any other person (including a primary care
provider) in order to obtain access to obstetrical or gynecological care from a health care professional in
our network who specializes in obstetrics or gynecology. The health care professional, however, may be
required to comply with certain procedures, including obtaining prior authorization for certain services,
following a pre-approved treatment plan, or procedures for making referrals. For a list of participating
health care professionals who specialize in obstetrics or gynecology, contact the BCN website at
www.bcbsm.com and call 800.662.6667.
Waiver of Medical Coverage – Opt Out Option
You may elect to waive medical coverage from Advia CU if you have and
can provide proof of existing coverage from another source (spouse,
parent, etc.). When proof of coverage is provided to Human Resources and
validated, you will be eligible to receive the Opt-Out Option amount in each
pay.
The Opt Out amount is $2,400 for the year, and is paid out in 26 equal
amounts, $92.31 in each pay period.
Should you require to be added to Advia CU’s medical plan, the opt out
amount will cease when medical coverage begins.
Summary of Benefits & Coverage (SBC)
In accordance with the changes mandated by federal health care reform effective the first plan year
following 09/23/2012, your Summary of Benefits & Coverage (SBC) for our medical plans are enclosed.
The purpose of the SBC is to provide an explanation of your medical and prescription benefits (if any) in
an easy to read format. The SBC should look the same for any health plan from any employer since the
format, developed by the federal Department of Labor (DOL), is mandatory.
The SBC should be used in conjunction with the benefit table in the Medical Coverage section of this
booklet and the benefit guide found in the Member Section of the carrier’s website, on your Employee
Home Page on SAM or by clicking HERE.
Salus Group© Copyright 2014 Page | 10
