PHYSICIAN BENEFIT SECTION Clause Samples

PHYSICIAN BENEFIT SECTION. The following provisions are added to the Non‐Participating Provider payment level under BENEFIT PAYMENT FOR PHYSICIAN SERVICES: When you receive Covered Services, from a Participating Hospital or from a Plan Ambulatory Surgical Facility and, due to any reason, Covered Services for anesthesiology, pathology, radiology, neonatology or emergency room are unavail- able from a Participating Provider and Covered Services are provided by a Non‐Participating Provider, you will incur no greater out‐of‐pocket costs than you would have incurred if the Covered Services were provided by a Participating Provid- er. However, in the event that you willfully choose to receive Covered Services from a Non‐Participating Provider when a Participating Professional Provider is available, or you or the Non‐Participating Provider reject the assignment of bene- fits, the above provision will not apply to you. Blue Cross and Blue Shield, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company ▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ President, Retail Markets DB‐A93 HCSC 01395.0611 A The “Women’s Health and Cancer Rights Act of 1998” requires that plans covering mastectomies also cover reconstructive surgery following mastectomies. Specifically, because your Blue Cross and Blue Shield of Illinois health insurance policy covers mastectomies, we also cover the following procedures: • Reconstruction of the breast on which the mastectomy has been performed • Surgery and reconstruction of the other breast to produce a symmetrical appearance • Prostheses and treatment for physical complications at all stages of mastectomy, including lymphodema, in a manner determined in consultation with the attending physician and the patient This benefit applies immediately and is subject to the applicable deductible and coinsurance provisions of your coverage. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association ®Registered Service Marks of the Blue Cross and Blue Shield Association of Independent Blue Cross and Blue Shield Plans 30094.0404 IL NOTICE TO APPLICANT REGARDING REPLACEMENT According to information you have furnished, you intend to lapse or otherwise terminate existing health insurance and replace it with a policy to be used by Health Care Service Corporation. For your own information and protection, you should be aware of and seriously consider factors which may affect the insurance protection a...