Page 43 - 2022 MLB Benefit Guide 08.2022

Benefit Network Out-of-Network
Therapy and Rehabilitation Services
Physical Medicine 100% after $15 copayment 80% after deductible
Limit: 70 visits per benefit period combined with Occupational and Speech Therapy
Occupational Therapy 100% after $15 copayment 80% after deductible
Limit: 70 visits per benefit period combined with Physical Medicine and Speech Therapy
Speech Therapy 100% after $15 copayment 80% after deductible
Limit: 70 visits per benefit period combined with Physical Medicine
and Occupational Therapy
Respiratory Therapy 100% (deductible does not apply)
Spinal Manipulations 100% after $15 copayment 80% after deductible
Limit: 20 visits per benefit period
Other Therapy Services (Cardiac Rehab, Infusion Therapy, 100% 80% after deductible
Chemotherapy, Radiation Therapy and Dialysis)
Mental Health/Substance Abuse
Inpatient 100% 80% after deductible
Inpatient Detoxification/Rehabilitation
Outpatient 100% after $15 copayment 80% after deductible
Autism(3) 100% 80% after deductible
Other Services
Allergy Extracts and injections 100% 80% after deductible
Assisted Fertilization Procedures 100% 80% after deductible
Dental Services Related to Accidental Injury 100% 80% after deductible
Diagnostic Services 100% 80% after deductible
Advanced Imaging (MRI, CAT, PET scan, etc.)
Basic Diagnostic Services (standard imaging, diagnostic 100% 80% after deductible
medical, lab/pathology, allergy testing)
Durable Medical Equipment, Orthotics and Prosthetics 100% 80% after deductible
Hearing Care Services 100% 80% after deductible
Limit:
• Frequency for up to age 18 is 1 hearing aid per ear per every two
years
• Frequency for over age 18 is 1 hearing aid per ear per every five
years

Home Health Care/Visiting Nurse(4) 100% 80% after deductible
Hospice 100% 80% after deductible
Infertility Counseling, Testing and Treatment(5) 100% 80% after deductible
Private Duty Nursing 100% (deductible does not apply)
Skilled Nursing Facility Care 100% 80% after deductible
Limit: 100 days per benefit period
Transplant Services 100% 80% after deductible
Precertification Requirements(6) Yes
Prescription Drug
Prescription Drug Deductible
Individual/Family None
Prescription Drug Program(7)(8) Retail Drugs
Defined by the National Plus Pharmacy Network - Not Physician $10 Generic copayment
Network. Prescriptions filled at a non-network pharmacy are not $20 Brand copayment
covered. $35 Brand Non-Formulary
Mandatory generic
31 day supply

Maintenance Drugs through Mail Order
$20 Generic copayment
$40 Brand copayment
$70 Brand Non-Formulary
Mandatory generic
90 day supply
Questions? 1-800-701-2324
(1) Your group's benefit period is based on a Calendar Year which runs from January 1 to December 31.
(2) The Network Total Maximum Out-of-Pocket (TMOOP) is mandated by the federal government, TMOOP must include deductible, coinsurance, copays, prescription drug cost share and any qualified medical
expense.
(3) Coverage for eligible members. Services will be paid according to the benefit category, i.e., speech therapy. Treatment for autism spectrum disorders does not reduce visit/day limits.
(4) The maternity home health care visit for network care is not subject to the program copayment, coinsurance or deductible amounts, if applicable. See Maternity Home Health Care Visit in the Covered
Services section.
(5) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered depending on your group’s prescription drug
program.
(6) BCBS Medical Management & Policy (MM&P) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related inpatient admission. Be sure to verify that
your provider is contacting MM&P for precertification. If not, you are responsible for contacting MM&P. If this does not occur and it is later determined that all or part of the inpatient stay was not medically
necessary or appropriate, you will be responsible for payment of any costs not covered.
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