Primary Care Clinic Employees and each of their covered dependents must individually elect a primary care clinic within the network of providers offered by the plan administrator chosen by the employee. Employees and their dependents may elect to change clinics within their clinic’s Benefit Level as often as the plan administrator permits and as outlined above.
Restricted Use By Outsourcers / Facilities Management, Service Bureaus or Other Third Parties Outsourcers, facilities management or service bureaus retained by Licensee shall have the right to use the Product to maintain Licensee’s business operations, including data processing, for the time period that they are engaged in such activities, provided that: 1) Licensee gives notice to Contractor of such party, site of intended use of the Product, and means of access; and 2) such party has executed, or agrees to execute, the Product manufacturer’s standard nondisclosure or restricted use agreement which executed agreement shall be accepted by the Contractor (“Non-Disclosure Agreement”); and 3) if such party is engaged in the business of facility management, outsourcing, service bureau or other services, such third party will maintain a logical or physical partition within its computer system so as to restrict use and access to the program to that portion solely dedicated to beneficial use for Licensee. In no event shall Licensee assume any liability for third party’s compliance with the terms of the Non-Disclosure Agreement, nor shall the Non-Disclosure Agreement create or impose any liabilities on the State or Licensee. Any third party with whom a Licensee has a relationship for a state function or business operation, shall have the temporary right to use Product (e.g., JAVA Applets), provided that such use shall be limited to the time period during which the third party is using the Product for the function or business activity.
Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers Quality healthcare begins with a partnership between you and your primary care provider (PCP). When you need care, call your PCP, who will help coordinate your care. Your healthcare coverage under this plan is provided or arranged through our network of PCPs, specialists, and other providers. You’re encouraged to: • become involved in your healthcare by asking providers about all treatment plans available and their costs; • take advantage of the preventive health services offered under this plan to help you stay healthy and find problems before they become serious. Each member is required to provide the name of his or her PCP. However, if the name of a PCP is not provided with the application, your enrollment will not be delayed and your coverage will not be cancelled. How to Find a PCP or Other Providers Finding a PCP in our network is easy. To select a provider, or to check that a provider is in our network, please use the “Find a Doctor” tool on our website or call Customer Service. Please note: We are not obligated to provide you with a provider. We are not liable for anything your provider does or does not do. We are not a healthcare provider and do not practice medicine, dentistry, furnish health care, or make medical judgments.
Secondary Cardholder You may not request an additional Card for another person.
AIN Selective Carrier Routing for Operator Services, Directory Assistance and Repair Centers 4.3.1 BellSouth will provide AIN Selective Carrier Routing at the request of <<customer_name>>. AIN Selective Carrier Routing will provide <<customer_name>> with the capability of routing operator calls, 0+ and 0- and 0+ NPA (LNPA) 555-1212 directory assistance, 1+411 directory assistance and 611 repair center calls to pre-selected destinations.
Hospice Care If you have a terminal illness and you agree with your physician not to continue with a curative treatment program, this plan covers hospice care services received in your home, in a skilled nursing facility, or in an inpatient facility.
Child Care A. Employees employed as of March 1 who meet the following criteria shall be eligible for a lump sum payment each year. Eligible employees may apply for this payment between March 1 and April 15 of each year. Payment shall be made within thirty (30) days of receipt of the completed application. Any application received after April 15 will be considered on a case by case basis and shall not be arbitrarily rejected.
Office Visit Copayments In each year of the Agreement, the level of the office visit copayment applicable to an employee and dependents is based upon whether the employee has completed the on-line Health Assessment during open enrollment and has agreed to opt-in for health coaching.
COVERED HEALTHCARE SERVICES This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.
Emergency Care Services If you experience a medical emergency while traveling outside our service area, go to the nearest emergency or urgent care facility. When you receive Out-of-Area covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for the Out-of-Area Covered healthcare services, if not a flat dollar copayment, is calculated based on the lower of: • the billed charges for your Out-of-Area covered healthcare services; or • the negotiated price that the Host Blue makes available to us. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price we have used for your claim because they will not be applied after a claim has already been paid. Negotiated (non–BlueCard Program) Arrangements With respect to one or more Host Blues, in certain instances, instead of using the BlueCard Program, we may process your claims for covered healthcare services through Negotiated Arrangements for National Accounts. The amount you pay for covered healthcare services under this arrangement will be calculated based on the negotiated price (refer to the description of negotiated price in the BlueCard® Program section above) made available to us by the Host Blue.
