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

 

Community Bluesm PPO – Plan 3

Benefits-at-a-Glance

(City of Saginaw Health Care Plan)

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

To find an in-network physician, click here.

To find an out of network physician, click here.

For mail order prescription drugs click here.

1-800-258-8000 for benefits coverage

Download the following Benefit forms here: MECA, HRA Reimbursement, Delta Dental,

Report any errors on this page to the Webmaster

 

 

This is intended as an easy to read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply to covered services. For a complete description of benefits, please see the applicable Blue Cross Blue Shield of Michigan certificates 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 your plan. This coverage is provided pursuant to a contract entered into in the state of Michigan and will be construed under the jurisdiction of and according to the laws of the state of Michigan.

 

Member's Responsibilities

Deductibles

CoPays

CoPay Dollar Maximums

Dollar Maximums

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/Substance Abuse

Other Covered Services

Prescription Drug Coverage

Member's Responsibilities (Copays)

Covered Services

Features of Your Plan

Riders

Member’s responsibility (deductibles, copays and dollar maximums)

Note: Services from a provider for which there is no PPO network and services from a non-network provider in a geographic area of Michigan deemed as a “low access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. 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.

 

 

In-network

Out-of-Network

 

Deductibles

$250 for one member, $500 for the family (when two or more members are covered under your contract) each calendar year

Note: Deductible waived if service is performed in a PPO physician’s office.

$1,000 for one member, $2,000 for the family (when two or more members are covered under your contract) each calendar year

Note: Deductible waived if service is performed in a PPO physician’s office.

Copays

·    Fixed dollar copays

 

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

 

$75 for emergency room visits

·    Percent copays

20% for general services (copay waived if the service is performed in a PPO physicians office) and 50% for mental health care, substance abuse treatment and private duty nursing

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

Copay dollar maximums

·    Fixed dollar copays

 

None

 

None

·    Percent copays – excludes mental health care, substance abuse treatment and private duty nursing copays

$1,000 for one member, $2,000 for two or more members each calendar year

$4,000 for one member, $8,000 for two or more members each calendar year

Note: Out-of-network copays also apply toward the in-network maximum.

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 for individual services.

 

Preventative care services – *Payment for preventative 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

Gynecological exam

Covered – 100%*, one per calendar year

Not covered

Pap smear screening – laboratory and pathology services

Covered – 100%*, one per calendar year

Not covered

Well-baby and child care

Covered – 100%*

·    6 visits, birth through 12 months

·    6 visits, 13 months through 23 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

Childhood immunizations as recommended by the Advisory Committee on Immunization Practices and the American Academy of Pediatrics

Covered – 100%*, one per calendar year

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

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Mammography

 

 

Mammography screening

Covered – 100%*, one per calendar year

Covered – 50% after deductible

One per calendar year, no age restrictions

 

Physician office services

 

 

Office visits

Covered - $20 copay per office visit

Covered – 50% after deductible, must be medically necessary

Outpatient and home medical care visits

Covered – 80% after deductible

Covered – 50% after deductible, must be medically necessary

Office consultations

Covered - $20 copay per office visit

Covered – 50% after deductible, must be medically necessary

Urgent care visits

Covered - $20 copay per office visit

Covered – 50% after deductible, must be medically necessary

 

Emergency medical care

 

 

Hospital emergency room

Covered - $75 copay per visit (copay waived if admitted or for an accidental injury)

Covered - $75 copay per visit (copay waived if admitted or for an accidental injury)

Ambulance services – must be medically necessary

Covered – 80% after deductible

Covered – 80% after deductible

 

Diagnostic services

Laboratory and pathology services

Covered – 80% after deductible

Covered – 50% after deductible

Diagnostic tests and x-rays

Covered – 80% after deductible

Covered – 50% after deductible

Therapeutic radiology

Covered – 80% after deductible

Covered – 50% after deductible

 

Maternity services provided by a physician

Prenatal and postnatal care

Covered – 100%

Covered – 50% after deductible

Includes care provided by a certified nurse midwife

Delivery and nursery care

Covered – 80% after deductible

Covered – 50% after deductible

Includes delivery provided by a certified nurse midwife

 

Hospital care

 

 

Semiprivate room, inpatient physician care, general nursing care, hospital services and supplies

Note: Nonemergency services must be rendered in a participating hospital

Covered – 80% after deductible

Covered – 50% after deductible

Unlimited days

Inpatient consultations

Covered – 80% after deductible

Covered – 50% after deductible

Chemotherapy

Covered – 80% after deductible

Covered – 50% after deductible

 

Alternatives to hospital care

Skilled nursing care

Covered – 80% after deductible

Covered – 80% after deductible

Up to 120 days per member per calendar year

Hospice care

Covered – 100%

Covered – 100%

Limited to dollar maximum that is reviewed and adjusted periodically

Home health care – must be medically necessary

Covered – 80% after deductible

Covered – 80% after deductible

Home infusion therapy – must be medically necessary

Covered – 80% after deductible

Covered – 80% after deductible

 

Surgical services

Surgery – includes related surgical services and medically necessary facility services by a participating ambulatory surgery facility

Covered – 80% after deductible

Covered – 50% after deductible

Presurgical consultations

Covered – 100%

Covered – 50% after deductible

Colonoscopy

Covered – 80% after deductible

Covered – 50% after deductible

Voluntary sterilization

Covered – 80% after deductible

Covered – 50% after deductible

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Human organ transplants

 

 

Specified human organ transplants – in designated facilities only, when coordinated through the BCBSM Human Organ Transplant Program (800-242-3504)

Covered – 100%

Covered – in designated facilities only

Limited to $1 million lifetime maximum per member per transplant type for transplant procedure(s) and related professional, hospital and pharmacy services

Bone marrow transplants – when coordinated through the BCBSM Human Organ Transplant Program (800-242-3504)

Covered – 80% after deductible

Covered – 50% after deductible

Specified oncology clinical trials

Covered – 80% after deductible

Covered – 50% after deductible

Kidney, cornea and skin transplants

Covered – 80% after deductible

Covered – 50% after deductible

 

Mental health care and substance abuse treatment

Inpatient mental health care

Covered – 50% after deductible

Covered – 50% after deductible

Unlimited days

Inpatient substance abuse treatment

Covered – 50% after deductible

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% after deductible

 

Covered – 50% after deductible

Covered – 50%

Covered – 50% after deductible

Outpatient substance abuse treatment – in approved facilities only

Covered – 50% after deductible

Covered – 50% after deductible

Up to the state-dollar amount that is adjusted annually

 

Other covered services

Outpatient Diabetes Management Program (ODMP)

Covered – 80% after deductible

Covered – 50% after deductible

Allergy testing and therapy

Covered – 100%

Covered – 50% after deductible

Chiropractic manipulation treatment and osteopathic manipulation treatment

Covered – $20 copay per office visit

Covered – 50% after deductible

Up to a maximum of 24 visits per member per calendar year

Outpatient physical, speech and occupational therapy

Covered – 80% after deductible

Covered – 50% after deductible

Limited to a combined maximum of 60 visits per member per calendar year

Durable medical equipment

Covered – 80% after deductible

Covered – 80% after deductible

Prosthetic and orthotic appliances

Covered – 80% after deductible

Covered – 80% after deductible

Private duty nursing

Covered – 50% after deductible

Covered – 50% after deductible

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Blue Preferredβ Rx Prescription Drug Coverage

Benefits-at-a-Glance City of Saginaw

This is intended as an easy to read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply to covered services. For a complete description of benefits, please see the applicable Blue Cross Blue Shield of Michigan certificates 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 your plan. This coverage is provided pursuant to a contract entered into in the state of Michigan and will be construed under the jurisdiction of and according to the laws of the state of Michigan. 

Note: Effective October 1, 2006, the mail order pharmacy for specialty drugs changed to Option Care, an independent company. Specialty prescription drugs (such as Enbrelβ and Humiraβ) are used to treat complex conditions such as rheumatoid arthritis. These drugs require special handling, administration or monitoring. Option Care will handle mail order prescriptions only for specialty drugs while many retail pharmacies will continue to dispense specialty drugs (check with your local pharmacy for availability). Other mail order prescription medications can continue to be sent to Medco. (Medco is an independent company providing pharmacy benefit services for Blue members.) A list of specialty drugs is available on our Web site at bcbsm.com. Log in under “I am a Member.” If you have any questions, please call Option Care customer service at 865-515-1355.

 

 

 

90-day retail network pharmacy

Network mail order provider

Network pharmacy (not part of the 90-day retail network)

Non-network pharmacy

Member’s responsibility (copays)

Generic or prescribed over-the-counter drugs

1 to 34-day period

$10 copay

$10 copay

$10 copay

$10 copay plus 25% of the BCBSM approved amount for the drug

35 to 83-day period

No coverage

$10 copay

No coverage

No coverage

84 to 90-day period

$10 copay

$10 copay

No coverage

No coverage

Brand-name drugs

1 to 34-day period

$40 copay

$40 copay

$40 copay

$40 copay plus 25% of the BCBSM approved amount for the drug

35 to 83-day period

No coverage

$40 copay

No coverage

No coverage

84 to 90-day period

$40 copay

$40 copay

No coverage

No coverage

 

If your prescription is filled by any type of network pharmacy, and you request the brand-name drug when a generic equivalent is available on the BCBSM MAC list and the prescriber has not indicated “Dispensed as Written” (DAW) on the prescription, you must pay the difference in cost between the brand-name drug dispensed and the maximum allowable cost for the generic plus the applicable copay. 

Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law.

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*90-day retail network pharmacy

**Network mail order provider

Network pharmacy (not part of the 90-day retail network)

Non-network pharmacy

Covered Services

 

 

 

 

“Rx only” drugs

Covered – 100% less plan copay

Covered – 100% less plan copay

Covered – 100% less plan copay

Covered – 75% less plan copay

Prescribed over-the-counter drugs – when covered by BCBSM

Covered – 100% less plan copay

Covered – 100% less plan copay

Covered – 100% less plan copay

Covered – 75% less plan copay

State-controlled drugs

Covered – 100% less plan copay

Covered – 100% less plan copay

Covered – 100% less plan copay

Covered – 75% less plan copay

Disposable needles and syringes – when dispensed with insulin or other covered injectable legend drugs

Note: Needles and syringes have no copay.

Covered – 100% less plan copay for the insulin or other covered injectable legend drug

Covered – 100% less plan copay for the insulin or other covered injectable legend drug

Covered – 100% less plan copay for the insulin or other covered injectable legend drug

Covered – 75% less plan copay for the insulin or other covered injectable legend drug

 

*  Note: The member must have been on the medication, under BCBSM coverage, for at least 60 days out of the previous 120 days before being eligible for the 90-day supply. 

** Note: We will not pay for drugs obtained from non-network mail order providers, including Internet providers.

  

Features of your plan

Drug interchange and generic copay waiver

Certain drugs may not be covered for future prescriptions if a suitable alternate drug is identified by BCBSM, unless the prescribing physician demonstrates that the drug is medically necessary. A list of drugs that may require authorization is available at bcbsm.com

If your physician rewrites your prescription for the recommended generic or OTC alternate drug, you will only have to pay a generic copay. If your physician rewrites your prescription for the recommended brand-name alternate drug, you will have to pay a brand-name copay. In select cases BCBSM may waive the initial copay after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver.

Quantity limits

Select drugs may have limitations related to quantity and doses allowed per prescription unless the prescribing physician obtains preauthorization from BCBSM. A list of these drugs is available at bcbsm.com

 

 

Rider CI, Contraceptive injections

Rider PCD, Prescription contraceptive devices,

Rider PD-CM, Prescription contraceptive medications

Adds coverage for contraceptive injections, physician-prescribed contraceptive devices such as diaphragms and IUDs, and “Rx only” oral or injectable contraceptive medications.

Note: Riders CI and PCD are part of your medical-surgical coverage, subject to the same deductible and copay, if any, you pay for medical-surgical services. (Rider PCD waives the copay for services provided by a network provider.)

Rider PD-CM is part of your prescription drug coverage, subject to the same copay you pay for prescription drugs.

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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.

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IF YOU SELECT A NON-PANEL PROVIDER

 

Pick up a claim form from the office. Make an appointment with the doctor of your choice. After the examination, give the claim form to the doctor for completion, pay his fee, submit the completed claim form with the doctor's charge. MECA will reimburse the employee. Your correct address and zip code must appear on your claim form. Your claim must be submitted for payment within 90 days after your date of service.

 

Mail the completed claim form to:

MECA, INC.

P. 0. Box 17190

Indianapolis, Indiana 46217

 

Reimbursement will be mailed to you within 30 days after receiving a properly executed claim form. Please be sure that your correct address and zip code is on the claim form. You will be reimbursed per the following schedule for non-panel providers.

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Non-Panel Providers Maximum Payment

 

Vision Examination                          

                                                           

 

Single Vision Lenses                      

Bifocal Lenses                                 

Trifocal Lenses                                 

Lenticular Lenses                             

 

Frame                                               

 

Contact Lenses (Cosmetic)            

Contact Lenses (Med. Nec.)           

(In lieu of all other benefits)

$60.00 M.D.

$45.00 O.D.

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$60.00 

$85.00

$105.00

$200.00 

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$100.00

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$175.00

$175.00

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ELIGIBILITY

 

You are eligible for the vision care benefits described herein based upon an agreement with the City and if you are a permanent full time or permanent part time employee as defined by the City of Saginaw. You are eligible for the vision care benefits described herein on the first day of the month following your date of hire.

 

Eligible dependents are your spouse (except in the event of divorce or annulment) and your unmarried children less than 19 year old. Unmarried children age 19-25 who are full time students and are claimed on your tax return are covered as adult dependents. Unmarried children age 19 to 25 also are eligible as adult dependents provided they are physically or mentally disabled. Stepchildren, foster children and legally adopted children may be included the same as your natural children provided they depend upon you for support and maintenance.

 

The following persons are not eligible dependents:

1.      A person on active duty in any military, naval or air force of any country.

2.      A person insured under this plan as an employee.

 

In no event may a dependent child be covered by more than one employee. If more than one employee would otherwise cover the dependent child, the child may only be covered by the employee whose birthday occurs first in the year. For example, the employee whose birthday is January 1 covers the dependents rather than the employee whose birthday is January 2. Married couples enroll one person as single and one person as single with dependents. Employees cannot also be covered as a spouse because there is no double coverage.

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FREQUENCY OF BENEFITS

                                    EXAM             LENSES        FRAMES       CONTACTS

 

Adults-Employee & Spouse            Once every 24 consecutive months

 

Adult dependents 19-25                   Once every 24 consecutive months

                                                            (Full time students or disabled dependents)

 

Children under age 19                      Once every 12 consecutive months

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PLAN EXCLUSIONS AND LIMITATIONS

 

The vision plan is designed to cover your vision requirements rather than cosmetic purposes. An additional charge may be made if you select any of the following:

 

1.    Oversize lenses.

2.    Blended, progressive or executive lenses.

3.    The cost of a frame in excess of the plan allowance.

4.    More than one pair of glasses or contact lenses.

5.    The cost of contact lenses in excess of the plan allowance.

6.    Tinted, coated lenses or prism.

7.    Glasses that do not require a prescription.

8.    Surgical treatment of the eye.

9.    Medication for the eye.

10.  Special procedures, such as vision training, sub-normal vision aids or non-prescription lenses.

11.  Services or materials provided as a result of any Workman's Compensation Law.

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VISION EXAMINATION

A routine comprehensive examination including refraction and tonometry for eligible employees is covered. Additional testing may be an additional charge. The examination fee will be paid to the participating optometrist or ophthalmologist if you go to a panel doctor, the employee will be reimbursed according to the schedule listed for non-panel doctors.

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LENSES

If you go to a panel doctor your 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. If you go to a non-panel doctor your payments will be made according to the schedule listed.

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FRAMES

The MECA plan offers a variety of frames in the current styles. If you should select a frame 1 which is more than the amount allowed of $100.00 by this plan or an oversize frame which requires an oversize lens, you are responsible for the additional charge.

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CONTACT LENSES

When cosmetic contact lenses are selected you will be allowed $175.00 including an exam.

Contact lenses following surgery or when visual acuity is not correctable to 20170 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 $175.00 including an 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.

 

If you should have any questions, call 317-781-1060.

 

IF YOU OBTAIN YOUR CLAIM FORM AND GO TO A PANEL PROVIDER OTHER THAN IN YOUR IMMEDIATE AREA, PLEASE CONTACT OUR OFFICE FOR VERIFICATION THAT THE PANEL PROVIDER PARTICIPATES WITH YOUR GROUP.

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