BCBSAZ Ascend HMO Plus Plan Attachment Statewide HMO Network

Transcription

1 BCBSAZ Ascend HMO Plus Plan Attachment Statewide HMO Network GRP HMO ASD / Suite C

2 PLAN NETWORK Your Plan Network is the Statewide HMO Network. The BCBSAZ provider directory of Statewide HMO Network providers is available online at If you do not have Internet access, or you have questions about a provider s network participation, please call BCBSAZ Customer Service before you receive services. GRP HMO ASD /18 1 STE C STA

3 MEMBER COST-SHARING Members pay part of the costs for benefits received under this plan. Depending on your particular benefit plan, the service you receive and the provider you choose, you may have an access fee, coinsurance, copay, deductible or some combination of these payments. Each cost-share type is explained below. This section, the benefit descriptions in this book, and your SBC will explain which cost-share types apply to each benefit. BCBSAZ uses your claims to track whether you have met some cost-share obligations. We apply claims based on the order in which we process the claims and not based on date of service. Access Fee An access fee is a fixed fee you pay to a provider for certain covered services, usually at the time of service. If an access fee applies to a particular service, you must pay the access fee plus any other applicable costshare for the service. Access fees do not count toward meeting your calendar-year deductible. Benefit Maximums Some benefits may have a specific benefit maximum or limit based on the number of days or visits, type, timeframe (calendar year or benefit plan), age, gender or other factors. If you reach a benefit maximum, any further services are not covered under that benefit and you may have to pay the provider s billed charges for those services. However, if you reach the benefit maximum on a particular line of a claim, you will be responsible for paying only up to the allowed amount for the remaining charges on that line of the claim. All benefit maximums are included in the applicable benefit description. Calendar-Year Deductible (Individual and Family) A calendar-year deductible is the amount each member must pay for covered services each January through December before the benefit plan begins to pay for covered services. The deductible applies to every covered service unless the specific benefit section says it does not apply. If you have family coverage, there is also a calendar-year deductible for the family. Amounts counting toward an individual s calendar-year deductible will also count toward any family deductible. When the family satisfies its calendar-year deductible, it also satisfies the deductible for all the individual members. An individual member cannot contribute more than his or her individual deductible toward the family s deductible. The deductible is calculated based on the allowed amount. Amounts you pay for copays and access fees do not count toward the deductible. Coinsurance Coinsurance is a percentage of the allowed amount that you pay for certain covered services after meeting any applicable deductible. BCBSAZ subtracts any applicable access fees and precertification charges from the allowed amount before calculating coinsurance. Coinsurance applies to every covered service unless the specific benefit section says it does not apply. BCBSAZ normally calculates coinsurance based on the allowed amount. There is one exception. If a hospital provider s billed charges are less than the hospital s reimbursement, BCBSAZ will calculate your coinsurance based on the lesser billed charge. Copay A copay is a specific dollar amount you must pay to the provider for some covered services. If a copay applies to a covered service, you must pay it when you receive services. Different services may have different copay amounts and are shown on your SBC. Usually, if a copay does not apply, you will pay applicable deductible and coinsurance. Out-of-Pocket Maximum (Individual & Family) An out-of-pocket maximum is the amount each member must pay each year before the plan begins paying 100 percent of the allowed amount on covered services, for the remainder of the calendar year. The payments listed below do not count toward the out-of-pocket maximum. You must keep paying them even after you reach your out-of-pocket maximum: Amounts above a benefit maximum Any amounts for noncovered services Any charges for lack of precertification GRP HMO ASD /18 2 STE C STA

4 If you have family coverage, there is an out-of-pocket maximum for your family. Amounts applied to each member s out-of-pocket maximum also apply to the family out-of-pocket maximum. The family maximum is applied in the same way as the individual maximum described above and is subject to the same rules. When the family has met its family out-of-pocket maximum, it also satisfies the out-of-pocket maximum requirements for all the individual members. GRP HMO ASD /18 3 STE C STA

5 COST-SHARE GRID AND TABLE The following grid shows your cost-share for covered services. For most services, you will pay Plan Deductible and Plan Coinsurance, or a copay. Services Out-of-Pocket Maximum Calendar-Year Plan Deductible Plan Coinsurance 20% Primary Care Physician (PCP) Copay $25 Specialist Copay $45 Amount $6,350 per member $12,700 per family $3,000 per member $6,000 per family Emergency Room Copay $ Bariatric Surgery Access Fee $1,000 18, 24 Level 1 Pharmacy Copay $15 25 Level 2 Pharmacy Copay $45 25 Level 3 Pharmacy Copay $75 25 Level 4 Pharmacy Copay $ Level A Specialty Medication Copay $60 34 Level B Specialty Medication Copay $ Level C Specialty Medication Copay $ Level D Specialty Medication Copay $ Telehealth Medical Copay $10 35 Telehealth Counseling Copay $20 35 Telehealth Psychiatry Copay $45 35 Urgent Care Copay $60 39 Corresponding Table Benefit Number 1-10, 12-13, 15, 17-30, 32-37, , 12, 15, 17-21, 23-24, 26 30, 36-37, , 12-13, 15, 17-24, 26-30, 32-33, 36-37, 39 3, 4-6, 8, 10, 21, 23-24, 27-29, 32, 36-37, 39 3, 4-8, 10, 21, 23-24, 27-29, 32, 36-37, 39 GRP HMO ASD /18 4 STE C STA

6 COST-SHARE TABLE Benefit 1. AMBULANCE You pay Plan Deductible and Plan Coinsurance. 2. BEHAVIORAL AND MENTAL HEALTH (Inpatient): 3. BEHAVIORAL AND MENTAL HEALTH (Outpatient Facility and Professional Services): 4. BEHAVIORAL THERAPY FOR THE TREATMENT OF AUTISM SPECTRUM DISORDER 5. CARDIAC AND PULMONARY REHABILITATION OUTPATIENT 6. CATARACT SURGERY & KERATOCONUS 7. CHIROPRACTIC 8. CLINICAL TRIALS FOR TREATMENT OF CANCER AND OTHER LIFE-THREATENING DISEASES 9. DENTAL BENEFIT MEDICAL 10. DURABLE MEDICAL EQUIPMENT (DME), MEDICAL SUPPLIES AND PROSTHETIC APPLIANCES AND ORTHOTICS 11. EDUCATION AND TRAINING (Diabetes and Asthma Education and Training; Nutritional Counseling and Training) 12. EMERGENCY (PROFESSIONAL AND FACILITY CHARGES) Facility and Professional Services: You pay Plan Deductible and Plan Coinsurance. You pay one copay per member, per provider, per day for services provided during an office, home or walk-in clinic visit. Your copay will vary depending on whether you see a PCP or a Specialist. You pay Plan Deductible and Plan Coinsurance for services delivered in locations other than the provider s office, the member s home or a walkin clinic. You pay one copay per member, per provider, per day for services provided during an office, home or walk-in clinic visit. Your copay will vary depending on whether you see a PCP or a Specialist. You pay Plan Deductible and Plan Coinsurance for services delivered in locations other than the provider s office, the member s home or a walkin clinic. services provided in a facility, and for outpatient facility charges. For physician office visits, you pay a PCP Copay or a Specialist Copay. services provided in a facility, and for inpatient and outpatient facility charges. For physician office visits, you pay a PCP Copay or a Specialist Copay. You pay a Specialist Copay per member, per provider, per day for services provided during an office, home or walk-in clinic visit. The copay does not apply if you receive only physical medicine and rehabilitation services and no other covered service during your visit. For physical medicine and rehabilitation services, you pay Plan Deductible and Plan Coinsurance. You pay Plan Deductible and Plan Coinsurance for services delivered in locations other than the provider s office, the member s home or a walk-in clinic. services provided in a facility, and for inpatient and outpatient facility charges. For physician office visits, you pay a PCP Copay or a Specialist Copay. You pay Plan Deductible and Plan Coinsurance. For services received in a physician s office, you pay a PCP Copay or a Specialist Copay. You pay Plan Deductible and Plan Coinsurance for services received outside a physician s office. Your cost-share is waived for one FDA-approved manual or electric breast pump and breast pump supplies per member, per calendar year. Your cost-share is waived. Emergency Room: You pay one emergency room copay per member, per facility, per day for emergency room facility and ancillary charges. Deductible and coinsurance are waived for professional services provided while in the emergency room. Admission to the hospital from the emergency room: If you are admitted as an inpatient: The emergency room copay is waived. GRP HMO ASD /18 5 STE C STA

7 Benefit You pay deductible and coinsurance for facility and ancillary services related to the emergency, including facility and ancillary services provided while you were in the emergency room. You pay deductible and coinsurance for emergency professional services provided after admission. If you are admitted for observation or as an outpatient: You pay the emergency room copay. You pay deductible and coinsurance for professional, facility and ancillary services related to the emergency and provided after admission for observation or as an outpatient. If you receive emergency services from a noncontracted facility or professional provider, BCBSAZ will base the allowed amount used to calculate your cost-share on the provider s billed charges. 13. EOSINOPHILIC GASTROINTESTINAL DISORDER For all non-emergency services following the emergency treatment and stabilization, see the Physician Services, Inpatient Hospital, and Outpatient Services cost-share sections of this Plan Attachment. Plan Deductible is waived. You pay the lesser of 25 percent of the Cost or Plan Coinsurance for Formula. Cost is defined as either billed charges, if the Formula is purchased from an out-ofnetwork provider, or the allowed amount, if purchased from a network provider. Formula is amino-acid based formula. 14. FAMILY PLANNING (CONTRACEPTIVES AND STERILIZATION) Implanted Devices: Your cost-share is waived for professional charges for implantation and/or removal (including follow-up care) of FDAapproved implanted contraceptive devices when the purpose of the procedure is contraception, as documented by your provider on the claim, and the device is inserted and/or removed in a physician office. See the Outpatient Services, Physician Services and Inpatient Hospital cost-share sections of this Plan Attachment for your costshare when the location of service is outside a physician office. Sterilization Procedures: Your cost-share is waived for professional and facility charges for FDA-approved sterilization procedures when the purpose of the procedure is contraception, as documented by your provider on the claim. Hormonal Contraceptive Methods: Your cost-share is waived for oral contraceptives, patches, rings and contraceptive injections. See the Physician Services and Pharmacy Benefit sections of the Benefit Book for benefits. Emergency Contraception: Your cost-share is waived for FDAapproved over-the-counter emergency contraception when prescribed by a physician or other provider. See the Physician Services section of the Benefit Book for benefits. Barrier Contraceptive Methods: Your cost-share is waived for diaphragms, cervical caps, cervical shields, condoms, sponges and spermicides. See the Physician Services and the Pharmacy Benefit sections of the Benefit Book for benefits. GRP HMO ASD /18 6 STE C STA

8 Benefit 15. HOME HEALTH You pay Plan Deductible and Plan Coinsurance. If you believe you have paid more for a self-administered version of a Cancer Treatment Medication than for an injected or intravenously administered version of a Cancer Treatment Medication, please contact the Customer Service number on your ID card. 16. HOSPICE Your cost-share is waived. 17. INPATIENT AND You pay Plan Deductible and Plan Coinsurance. OUTPATIENT DETOXIFICATION 18. INPATIENT HOSPITAL You pay Plan Deductible and Plan Coinsurance. You also pay a Bariatric Surgery Access Fee for all bariatric surgeries. The Bariatric Surgery Access Fee applies toward the professional charges for bariatric surgery. 19. INPATIENT REHABILITATION EXTENDED ACTIVE REHABILITATION (EAR) 20. LONG-TERM ACUTE CARE (INPATIENT) 21. MATERNITY Global Charge is a fee charged by the delivering provider that includes certain prenatal, delivery and postnatal services. Your cost-share is waived for facility charges for FDA-approved sterilization procedures when the purpose of the procedure is contraception, as documented by your provider on the claim. First 60 Days of Services in a Calendar Year: You pay Plan Deductible and Plan Coinsurance. Second 60 Days of Services in a Calendar Year: You pay Plan Deductible and 50 percent coinsurance. First 100 Days of Services: You pay Plan Deductible and Plan Coinsurance Days of Services: You pay Plan Deductible and 50 percent coinsurance, until you reach the 365-day benefit plan maximum. Inpatient Services: You pay Plan Deductible and Plan Coinsurance. Outpatient Services: You pay one (1) physician visit copay for your first prenatal office or home visit, which covers all physician services included in the physician s Global Charge. You pay one copay, per member, per provider, per day for other physician office or home visits not included in the Global Charge. Your copay will vary depending on whether you see a PCP or Specialist. You pay Plan Deductible and Plan Coinsurance for professional services in an outpatient facility, and for outpatient facility charges. Professional services provided in the member s home must be rendered by a network provider. Your cost-share will vary depending on the type of provider. Applicable cost-share is waived for maternity services covered under the Preventive Services benefit. Your cost-share obligations may be affected by the addition of a newborn or adopted child, as described in the Plan Administration section of the Benefit Book. If you have coverage only for yourself and no Dependents, addition of a child will result in a change from individual coverage to family coverage. If you currently have a per person deductible and out-of-pocket maximum, when a child is added to your plan, you will also be required to meet a family deductible and out-ofpocket maximum, and you may be required to pay additional premium. GRP HMO ASD /18 7 STE C STA

9 Benefit 22. MEDICAL FOODS FOR INHERITED METABOLIC DISORDERS Cost is defined as either billed charges, if the member buys the Medical Foods from an out-of-network provider or the allowed amount, if the member buys the Medical Foods from a network provider. 23. NEUROPSYCHOLOGICAL AND COGNITIVE TESTING 24. OUTPATIENT Plan Deductible is waived. You pay the lesser of 50 percent of the Cost or Plan Coinsurance. services provided in a facility, and for inpatient and outpatient facility charges. For physician office visits, you pay a PCP Copay or a Specialist Copay. Diagnostic Laboratory Services: You pay a PCP Copay or a Specialist Copay for services in a physician s office (copay is waived if you receive only covered laboratory services during your visit), except professional services provided by a pathologist or dermapathologist will be subject to Plan Deductible and Plan Coinsurance. You pay Plan Deductible and Plan Coinsurance for services provided in other locations. Radiology Services: You pay a PCP Copay or a Specialist Copay for services in a physician s office, except professional services provided by a radiologist will be subject to Plan Deductible and Plan Coinsurance. You pay Plan Deductible and Plan Coinsurance for services provided in other locations. Outpatient Facility Services (Including Outpatient Surgery): You pay Plan Deductible and Plan Coinsurance. You also pay a Bariatric Surgery Access Fee for all bariatric surgeries. The access fee applies toward the professional charges for bariatric surgery. Your cost-share is waived for facility charges for FDA-approved sterilization procedures when the purpose of the procedure is contraception as documented by your provider on the claim. Sleep Studies: You pay Plan Deductible and Plan Coinsurance. 25. PHARMACY BENEFIT If you are currently obtaining a covered Specialty Medication from a Specialty Pharmacy, you can receive that medication from a network retail pharmacy. Please call the Pharmacy Benefit Customer Service number on your ID card if you need assistance with this issue. If you are currently obtaining a covered medication from the network mail order pharmacy, you can receive that medication from a network retail pharmacy. Please contact the Pharmacy Medications Administered in an Outpatient Facility: You pay Plan Deductible and Plan Coinsurance. Medications Obtained From Retail/Mail Order Pharmacies: You pay a Level 1, Level 2, Level 3, or Level 4 Pharmacy Copay, depending on the Level of the medication. You pay the Level 4 copay for compound medications. No exceptions will be made regarding the assigned Level of a medication. BCBSAZ may change the Level of a medication at any time without notice. Other than as noted in this section, no exceptions will be made concerning the cost-share you will pay, regardless of the medical reasons requiring use of a particular medication, even when there is no equivalent medication on a lower Level or if you are unable to take a medication on the lower Level for any reason. Your cost-share is waived for preventive medications and for covered vaccines. BCBSAZ will determine which medications are considered preventive and for which your cost-share is waived. BCBSAZ also determines which vaccines are covered and for which your cost-share is waived. Contact the Pharmacy Benefit Customer Service number on your ID card for information on whether a drug is considered a preventive medication. GRP HMO ASD /18 8 STE C STA

10 Benefit Benefit Customer Service number on your ID card if you need assistance with this issue. If you believe you have paid more for a self-administered version of a Cancer Treatment Medication than for an injected or intravenously administered version of a Cancer Treatment Medication, please contact the Pharmacy Benefit Customer Service number on your ID card. If you are taking two or more prescription medications for a chronic condition, you may request early or short refills of eligible covered medications by contacting the Pharmacy Benefit Customer Service number on your ID card and requesting enrollment in the BCBSAZ Medication Synchronization program. If you are enrolled in the BCBSAZ Medication Synchronization program, your cost-share for eligible covered medications will be adjusted for any early or short refills of those medications. 26. PHYSICAL THERAPY (PT), OCCUPATIONAL THERAPY (OT), AND SPEECH THERAPY (ST) 27. PHYSICIAN If you receive preventive services, your cost-share may be waived. Your cost-share is waived for all FDA-approved contraceptive methods when prescribed by your provider and obtained at a network pharmacy, including the following: Condoms FDA-approved diaphragms, cervical caps and cervical shields FDA-approved emergency contraception for members of any age FDA-approved generic oral, patch, vaginal ring and injectable contraceptives FDA-approved brand oral, patch, vaginal ring and injectable contraceptives with no generic equivalent components Sponges and spermicides Contraceptives must be prescribed for or include the purpose of contraception and not be prescribed solely for some other medical reason to be covered with no member cost-share. For certain covered preventive medications and items obtained from a network pharmacy, your cost-share is waived for the generic version of the medication or item and you pay applicable cost-share for the brandname version of the medication or item. You may request an exception for waiver of cost-share for the brand name version of a preventive medication or item obtained from a network pharmacy. For information on the exception process, see the Benefit Description subsection of Section W. Pharmacy Benefit under Description of Benefits in the Benefit Book. You may obtain up to a 90-day supply of Maintenance Medications. If you receive a 31 to 60 day supply of medication, you will pay two times the applicable cost-share for a 30-day supply. If you receive a 61 to 90 day supply of medication from a network retail pharmacy, you will pay three times the applicable cost-share for a 30-day supply. You pay Plan Deductible and Plan Coinsurance. You pay one copay per member, per provider, per day for services provided during an office, home or walk-in clinic visit. Your copay will vary depending on whether you see a PCP or Specialist. Your copay is waived if you only receive the following services and no other covered service during your home or office visit: Covered allergy injections Covered immunizations Covered laboratory services Covered physical therapy, speech therapy, occupational therapy (PT, OT, ST); these services are subject to Plan Deductible and Plan Coinsurance You pay Plan Deductible and Plan Coinsurance for services delivered in locations other than the provider s office, the member s home or a walk-in clinic. Your cost-share will be waived for the following services, when the purpose of the procedure is contraception as documented by your provider on the claim: Professional physician services for FDA-approved sterilization procedures, regardless of the location of service. GRP HMO ASD /18 9 STE C STA

11 Benefit 28. POST-MASTECTOMY 29. PREGNANCY, TERMINATION 30. PRESCRIPTION MEDICATIONS FOR THE TREATMENT OF CANCER 31. PREVENTIVE You pay applicable cost-share for any tests, procedures, or services not listed in the Preventive Services section of the Benefit Book. 32. RECONSTRUCTIVE SURGERY AND 33. SKILLED NURSING FACILITY (SNF) 34. SPECIALTY MEDICATIONS If you are currently obtaining a Specialty Medication from a Professional physician services for fitting, implantation and/or removal (including follow-up care) of FDA-approved contraceptive devices provided during a physician office, home or walk-in clinic visit. FDA-approved implanted contraceptive devices. The following FDA-approved generic and brand with no generic equivalent prescription hormonal and barrier contraceptive methods and devices: patches, rings, contraceptive injections, diaphragms, cervical caps, cervical shields, condoms, sponges and spermicides. See the Guidance Regarding Preventive Medications section on for a list of contraceptive methods covered as preventive services under the Pharmacy Benefit of this plan. services provided by a radiologist or pathologist, including a dermapathologist, and for professional services related to a sleep study, even when the services are provided in a physician s office. You also pay Plan Deductible and Plan Coinsurance for medications administered in a physician s office. services provided in a facility, and for inpatient and outpatient facility charges. For physician office visits, you pay a PCP Copay or a Specialist Copay. services provided in a facility, and for inpatient and outpatient facility charges. For physician office visits, you pay a PCP Copay or a Specialist Copay. See the Pharmacy Benefit cost-share section to determine your costshare for services received through the Pharmacy Benefit. You pay Plan Deductible and Plan Coinsurance for medications received through your medical benefits. Your cost-share is waived, regardless of the location where services are provided, if: You receive one of the services listed in the Benefit Description subsection of the Preventive Services section of the Benefit Book; The procedure code, the diagnosis code or the combination of procedure codes and diagnosis codes billed by your provider on the line of the claim indicates the service is preventive; and The primary purpose of the visit at which services were rendered was for preventive care. For certain covered preventive medications and items obtained from a network pharmacy, your cost-share is waived for the generic version of the medication or item and you pay applicable cost-share for the brandname version of the medication or item. You may request an exception for waiver of cost-share for the brand name version of a preventive medication or item. See the Benefit Description subsection of Section CC. Preventive Services under Description of Benefits in the Benefit Book. services provided in a facility, and for inpatient and outpatient facility charges. For physician office visits, you pay a PCP Copay or a Specialist Copay. First 90 Days of Services in a Calendar Year: You pay Plan Deductible and Plan Coinsurance. Second 90 Days of Services in a Calendar Year: You pay Plan Deductible and 50 percent coinsurance. You pay a Level A, Level B, Level C or Level D Specialty Medication Copay for most medications, depending on the Level of the medication. For Cancer Treatment Medications that are also classified as Specialty Medications, you pay the Level 1 retail/mail order pharmacy copay. BCBSAZ determines which Cancer Treatment Medications are GRP HMO ASD /18 10 STE C STA

12 Benefit Specialty Pharmacy and need to receive that medication from a retail pharmacy instead, please call Pharmacy Benefit Customer Service at the number on your ID card. BCBSAZ and/or the PBM will decide whether you are eligible to receive the Specialty Medication from a retail pharmacy instead of a Specialty Pharmacy. If you believe you have paid more for a self-administered version of a Cancer Treatment Medication than for an injected or intravenously administered version of a Cancer Treatment Medication, please call Pharmacy Benefit Customer Service at the number on your ID card. If you are taking two or more prescription medications for a chronic condition, you may request early or short refills of eligible covered medications by calling Pharmacy Benefit Customer Service at the number on your ID card and requesting enrollment in the BCBSAZ Medication Synchronization program. If you are enrolled in the BCBSAZ Medication Synchronization program, your cost-share for eligible covered medications will be adjusted for any early or short refills of those medications. 35. TELEHEALTH 36. TELEMEDICINE classified as Specialty Medications. For certain Cancer Treatment Medications, as determined by BCBSAZ, you will receive a 15-day supply, and pay one-half of the Level 1 retail/mail order pharmacy copay, the first time you receive the medication. You will be able to refill the medication every 15 days, and you will continue to pay one-half of the Level 1 copay, for each refill during your first three months of treatment with the medication. If you experience side effects from the medication during the three-month period, your prescribing provider may change your medication. If you tolerate the medication, you will be able to refill the Cancer Treatment Medication for up to 30 days after three months of treatment. If a member obtains a Specialty Medication from a network provider other than a pharmacy contracted with BCBSAZ for the Specialty Medications benefit ( Specialty Pharmacy ), the medication is excluded from coverage under this benefit, but may be covered under another benefit and subject to the cost-sharing provisions and precertification requirements of that benefit. Additional Information About Medication Levels Copays are based on the Level to which BCBSAZ has assigned the medication at the time the prescription is filled. BCBSAZ may change the Level of a medication at any time without notice. Go to to view a list of contracted Specialty Pharmacies and the Specialty Medication list. To confirm the status and Level of a particular Specialty Medication, you may also call the Pharmacy Benefit Customer Service at the number on your ID card. No exceptions will be made concerning the assigned Level of a medication or the copay that will apply, regardless of the medical reasons requiring use of the medication. This means if you are taking a Level B, C or D medication, you pay the applicable copay for that Level even if there is no equivalent medication on a lower Level or you are unable to take a medication on the lower Level for any reason. The assignment of a medication to any particular Level is not a recommendation on the use of a medication. You pay a Telehealth Medical Copay, a Telehealth Counseling Copay or a Telehealth Psychiatry Copay, depending on the type of telehealth consultation you receive. You pay all cost-share amounts applicable to the services provided via telemedicine. Cost-share applies for the service provided at your physical location, and also for the service rendered remotely by the telemedicine provider. To illustrate: if you are in a PCP s office and receiving a consultation from a remote specialist, you will pay the costshare applicable for a PCP office visit and the cost-share applicable for a specialist office visit or consultation. If you are at home and receiving a consultation from a remote specialist, you would pay only the costshare for the specialist because no other provider is involved at your location. The cost-share applicable to the services rendered by each provider involved in your telemedicine care, as shown in each specific benefit section, determine whether you pay deductible, coinsurance, copays and/or access fees. GRP HMO ASD /18 11 STE C STA

13 Benefit 37. TRANSPLANTS ORGAN - TISSUE BONE MARROW TRANSPLANTS AND STEM CELL PROCEDURES services provided in a facility, and for inpatient and outpatient facility charges. For physician office visits, you pay a PCP Copay or a Specialist Copay. If both a donor and a transplant recipient are covered by a BCBSAZ plan or a plan administered by BCBSAZ, the transplant recipient pays the cost-share related to the transplant. 38. TRANSPLANT TRAVEL Your cost-share is waived. AND LODGING 39. URGENT CARE You pay an Urgent Care Copay per member, per provider, per day for services received from a provider who is contracted with the Plan Network to render urgent care services. If you receive urgent care services from a Plan Network provider who is not specifically contracted for urgent care services, you pay a PCP Copay or Specialist Copay for services in a physician s office, home visit or walk-in clinic, and Plan Deductible and Plan Coinsurance for services in all other locations. GRP HMO ASD /18 12 STE C STA

14 NONDISCRIMINATION STATEMENT Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call (602) for Spanish and (877) for all other languages and other aids and services. If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: BCBSAZ s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ , (602) , TTY/TDD (602) , crc@azblue.com. You can file a grievance in person or by mail or . If you need help filing a grievance BCBSAZ s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at GRP HMO ASD /18 13 STE C STA

15 MULTI-LANGUAGE INTERPRETER GRP HMO ASD /18 14 STE C STA