This is information for Saginaw Firefighters Local 102 concerning our Health, Dental & Vision Benefits

 

Community Bluesm PPO

Benefits-at-a-Glance

(City of Saginaw Health Care Plan)

For information about your Health Care Plan call 1-989-759-1446

To find a in-network physician, click here.

For mail order prescription drugs click here.

1-800-225-BLUE for out of state in network physicians
1-800-258-8000 for benefits coverage

Download the following Benefit forms here: MECA, HRA Reimbursement, Delta Dental, Canada Life Beneficiary Designation

Report any errors on this page to the Webmaster

 
HEALTH BLUE COMMUNITY BLUE PPO Preferred Rx Prescription Drug Coverage
Preventative Care Services
Mammography
Physician Office Services
Emergency Medical Care
Diagnostic Services
Maternity Services Provided by a Physician
Hospital Care
Alternatives to Hospital Care
Surgical Services
Human Organ Transplants
Mental Health Care and Substance Abuse Treatment
Other Services
Deductible, Copay and Dollar Maximums		 Covered Services
Copays

 

In-Network

Out-of-Network

  

Preventative Care Services

*Payment for preventive services is limited to a combined maximum of $500 per member per calendar year

Health Maintenance Exam - includes chest X-ray, EKG and select lab procedures

Covered - 100%*, one per calendar year

Not covered

Annual Gynecological Exam

Covered - 100%*, one per calendar year

Not covered

Pap Smear Screening - laboratory services only

Covered - 100%*, one per calendar year

Not covered

Well-Baby and Child Care

Covered - 100%*

  • 6 visits, birth through 12 months
  • 2 visits, 24 months through 35 months
  • 2 visits, 36 months through 47 months
  • 1 visit per birth year, 48 months through age 15

Not covered

Immunizations

Covered - 100%*, up through age 16

Not covered

Fecal Occult Blood Screening

Covered - 100%*, one per calendar year

Not covered

Flexible Sigmoidoscopy Exam

Covered - 100%*, one per calendar year

Not covered

Prostate Specific Antigen (PSA) Screening

Covered - 100%*, one per calendar year

Not covered

Mammography

Mammography Screening

Covered - 100%

Covered - 50% after deductible

Physician Office Services

Office Visits

Covered - $20 copay

Covered - 50% after deductible, must be medically necessary

Outpatient and Home Visits

Covered - 100%

Covered - 50% after deductible, must be medically necessary

Office Consultations

Covered - $20 copay

Covered - 50% after deductible, must be medically necessary

Urgent Care Visits

Covered - $20 copay

Covered - 50% after deductible, must be medically necessary

Emergency Medical Care

Hospital Emergency Room

$75 copay, waived if admitted or for an accidental injury

$75 copay, waived if admitted or for an accidental injury

Ambulance Services - medically necessary

Covered - 100%

Covered - 100%

Diagnostic Services

Laboratory and Pathology Tests

Covered - 100%

Covered - 50% after deductible

Diagnostic Tests and X-rays

Covered - 100%

Covered - 50% after deductible

Radiation Therapy

Covered - 100%<

Covered - 50% after deductible

Maternity Services Provided by a Physician

Pre-Natal and Post-Natal Care

Covered - 100%

Covered - 50% after deductible

Includes care provided by a certified nurse midwife

Delivery and Nursery Care

Covered - 100%

Covered - 50% after deductible

Includes care provided by a certified nurse midwife

Hospital Care

Semi-Private Room, Inpatient Physician Care, General Nursing Care, Hospital Services and Supplies.

Note: Non-emergency services must be rendered in a participating hospital.

Covered - 100%

Covered - 50% after deductible

Unlimited days

Inpatient Consultations

Covered - 100%<

Covered - 50% after deductible

Chemotherapy

Covered - 100%

Covered - 50% after deductible

Alternatives to Hospital Care

Skilled Nursing Care

Covered - 100%

Covered - 100%

Up to 120 days per calendar year

Hospice Care

Covered - 100%

Covered - 100%

Limited to lifetime dollar maximum which is adjusted periodically

Home Health Care

Covered - 100%

Covered - 100%

Unlimited visits

Surgical Services

Surgery - includes related surgical services

Covered - 100%

Covered - 50% after deductible

Voluntary Sterilization

Covered - 100%

Covered - 50% after deductible

Human Organ Transplants

Specified Organ Transplants - in designated facilities only, when coordinated through the BCBSM Human Organ Transplant Program (1-800-242-3504)

Covered - 100%

Covered - in designated facilities only

Up to $1 million maximum per transplant type

Bone Marrow - when coordinated through the BCBSM Human Organ Transplant Program (1-800-242-3504); specific criteria applies

Covered - 100%

Covered - 50% after deductible

Kidney, Cornea and Skin

Covered - 100%

Covered - 50% after deductible

Mental Health Care and Substance Abuse Treatment

Inpatient Mental Health Care

Covered - 50%

Covered - 50% after deductible

Unlimited days

Inpatient Substance Abuse Treatment

Covered - 50%

Covered - 50% after deductible

Unlimited days - up to $15,000 annual, $30,000 lifetime maximum

Outpatient Mental Health Care

Facility and Clinic

Physician's Office

Covered - 50%

Covered - 50%

Covered - 50%

Covered - 50% after deductible

Outpatient Substance Abuse Treatment - in approved facilities

Covered - 50%

Covered - 50%

Up to the state-dollar amount which is adjusted annually

Other Services

Allergy Testing and Therapy

Covered - 100%

Covered - 50% after deductible

Chiropractic Spinal Manipulation

Covered - $20 Co-Pay

Covered - 50% after deductible

Up to 24 visits per calendar year

Up to 24 visits per calendar year

Outpatient Physical, Speech and Occupational Therapy

Facility and Clinic

Physician's Office - excludes speech and occupational therapy

Covered - 100%

Covered 100%

Covered - 100%

Covered - 100%

A combined 60 visit maximum per calendar year for physical therapy in the outpatient department of a hospital as well as in the physician's office

Durable Medical Equipment

Covered - 100%

Covered - 100%

Prosthetic and Orthotic Appliances

Covered - 100%

Covered - 100%

Private Duty Nursing

Covered - 50%

Covered - 50%

Deductible, Copay and Dollar Maximums

Note: If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge.

Deductible

None

$1000 per member, $2000 family per calendar year

Copays

Fixed Dollar Copays

$20 for office visits and $75 for emergency room visits

$75 for emergency room visits

Percent Copays

50% for mental health care, substance abuse treatment and private duty nursing

50% for general services and 50% for mental health care, substance abuse treatment and private duty nursing. Note: Services without a network are covered at the in-network level.

Copays

Fixed Dollar Copays

Percent Copays - excludes mental health care, substance abuse treatment and private duty nursing copays

None

None

Not applicable

$4000 per member, $8000 family per calendar year

Dollar Maximums

$1 million lifetime per covered specified human organ transplant type and a separate $5 million lifetime per member for all other covered services and as noted above for individual services

Rider CI, Contraceptive Injections , Rider PCD, Prescription Contraceptive Devices

Adds coverage for contraceptive injections, physician-prescribed contraceptive devices such as diaphragms and IUDs.

Blue Preferred Rx Prescription Drug Coverage

with $10 Generic/$40 Brand Name (actually $10/$20) Fixed Dollar Copay

Benefits-at-a-Glance

 

In-Network

Out-of-Network

Covered Services

Federal Legend Drugs

Covered - 100% less plan copay

Covered - 75% less plan copay

State-controlled Drugs

Covered - 100% less plan copay

Covered - 75% less plan copay

Needles and Syringes =96 dispensed with insulin

Covered - 100% less plan copay for insulin

Covered - 75% less plan copay for insulin

Mail Order Prescription Drugs =96 up to 90 day supply of medication by mail from Merck-Medco Rx Services

Covered - 100% less plan copay

Not Covered

Copays

Generic Drugs

$10 for each generic drug

$10 for each generic drug

Brand name Drugs

$40 for each brand name drug

$40 for each brand name drug

Out-of-Network Sanction

Not Applicable

25% plus applicable copay

Mail Order Prescription Drugs (Rider MOPD) www.medcohealth.com

$10 for each generic drug; $40 for each brand name drug

25% plus applicable copay

Rider PD-CM, Prescription Contraceptive Medications

Adds benefits to the Prescription Drug Plan for prescription oral or injectable contraceptive medications.

Not Applicable

Note: A network pharmacy is a Preferred Rx pharmacy in Michigan or a Merck-Medco Managed Care PAID Prescription (PAID) Coordinated Care Network-Level III (CCN-III) pharmacy outside Michigan. A non-network pharmacy is a pharmacy not part of the Preferred Rx or PAID CCN-III networks.

This is intended as an easy to read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. For an official description of benefits, please see the applicable Blue Cross Blue Shield of Michigan certificate and riders. Payment amounts are based on the Blue Cross Blue Shield of Michigan approved amount, less any applicable deductible and/or copay amounts required by the plan. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan.

Delta Premier

Summary of Dental Plan Benefits

For Group #0001983-0006

CITY OF SAGINAW

  Control Plan - Delta Dental Plan of Michigan

  Benefit Year - January 1 through December 31

Covered Services -

Delta Dental Pays

You Pay

Class I Benefits

 

 

Diagnostic and Preventive Services - Used to diagnose and/or prevent dental abnormalities or disease (includes exams, cleanings and fluoride treatments)

100%

0%

Emergency Palliative Treatment - Used to temporarily relieve pain

100%

0%

Class II Benefits

 

 

Radiographs - X-rays

50%

50%

Oral Surgery Services - Extractions and dental surgery, including preoperative and postoperative care

50%

50%

Endodontic Services - Used to treat teeth with diseased or damaged nerves (for example, root canals)

50%

50%

Periodontic Services - Used to treat diseases of the gums and supporting structures of the teeth

50%

50%

Relines and Repairs - Relines and repairs to bridges and dentures

50%

50%

Minor Restorative Services - Used to repair teeth damaged by disease or injury (for example, amalgam [silver] and resin [white] fillings)

50%

50%

Major Restorative Services - Used when teeth can't be restored with another filling material (for example, crowns)

50%

50%

Class III Benefits

 

 

Prosthodontic Services - Used to replace missing natural teeth (for example, bridges and dentures)

50%

50%

Class IV Benefits

 

 

Orthodontic Services (to age 19) - Used to correct malposed teeth and/or facial bones (for example, braces)

50%

50%

Maximum Payment - $800 per person total per benefit year on Class 1, Class 11 and Class III Benefits. Delta Dental's payment for Class IV Benefits will not exceed a lifetime maximum of $1,200 per eligible person. 

Deductible - None. 

Waiting Period - Employees hired after January 1, 2001 who are eligible for dental benefits are covered on the first day of the month following the date of hire.

Eligible People - Firefighters and retired firefighters who retired after October 1, 1980 and prior to June 7, 1999 of the contractor (your employer).

Also eligible are your legal spouse, your dependent children to the end of the calendar year in which they turn 19 and your dependent unmarried children who are eligible to be claimed by you as a dependent under the U.S. Internal Revenue code during the current calendar year.

Where two subscribers are eligible under the same group and are legally married to each other, they will be enrolled under two application cards and will receive benefits under the separate Delta Dental contracts. The contractor pays the full cost of this plan.

Benefits will cease on the last day of the month in which the employee is terminated.
MUTUAL EYE CLAIMS AUDITS, INC. (MECA)

CITY OF SAGINAW

PLAN B

VISION BENEFIT

 

Table of Contents

 

If you select a MECA Panel Provider

If you select a Non-Panel Provider

Non-Panel Maximum Payment

Eligibility

Frequency of Benefits

Plan Exclusions and Limitations

Vision Examinations

Lenses

Frames

Contact Lens

 

TO USE THE VISION PLAN

 

The claim forms will be disbursed from Human Resources.

 

IF YOU SELECT A MECA PANEL PROVIDER

 

Select a doctor and make an appointment for an examination. Advise your doctor you are enrolled in a MECA plan and give them your social security number to verify eligibility. Present the claim form to the doctor on your first visit. When the examination is completed the doctor will ask you to sign the claim form to verify that the services were performed. A routine comprehensive eye exam including refraction and tonometry is covered as follows. If you see a panel optometrist (OD) or ophthalmologist (MD), your exam will be covered in full. Additional testing may be an additional charge.

 

If you choose cosmetic contact lenses you will be allowed up to $175.00 and this includes the exam. There could be an additional charge for a contact lens examination because fittings and follow-up visits are not Included In the above exam benefit. Contact lenses following surgery or when visual acuity is not correctable to 20/70 in the better eye with conventional lenses, but can be corrected to 20/70 or better by use of contact lenses, are considered medically necessary which allows $175 including the exam. Medically necessary must be indicated on the claim form under contact lenses. You may select contacts or glasses in a 24-month benefit period.

 

65MM single vision, bifocal, trifocal or lenticular lenses will be covered in full. You will be responsible for any 'extras not covered by the plan. See the list of exclusions for details.

 

Select a frame of your choice. If you choose a frame over $100.00 you will be responsible for the amount in excess of $100.00.

 

The doctor will bill us for all allowable benefits. You will be responsible for any extras not covered by your plan. Your claims must be submitted for payment within 90 days after your date of service.