Summary of Benefits

The Teamsters Local 251 Health Services and Insurance Plan offers you and your eligible dependents a comprehensive package of benefits. Your coverage includes Medical, Prescription Drug, Dental, Vision, Legal, MAP, Hearing, Life Insurance and Weekly Accident and Sickness.

The Trustees have chosen the Blue Cross Blue Shield HealthMate Coast to Coast Plan to provide you with quality medical care and CVS/Caremark for prescription drug benefits. Through HealthMate Coast to Coast, you also get the convenience and cost savings of the BlueCard PPO network, although you have the freedom to visit any provider you'd like.

The following pages contain a brief overview of Level I benefits, including a summary of your life insurance, Accident Insurance and Disability benefits. These benefits are described in Section 8: Life and Dismemberment Insurance and WA&S. For Legal Services, refer to Section 9 for benefits provided. Your Medical Benefits are described in greater detail later in this section.

Benefit	You Pay		Notes
	PPO	Non-PPO
Annual Out-of-Pocket Maximum	$0	$5,000 per Person $10,000 per Family	If your copayments to a non-participating BlueCard PPO Network provider exceed the annual out-of-pocket maximum, the Plan will increase your coverage for most services from 80% to the full allowable amount for the rest of the calendar year. Deductible, penalties, flat dollar copay, infertility copays, and injectable drug copays do not apply to the annual out-of-pocket expenses.
Annual Deductible	$100 per person, up to 2 members per family per calendar year	$375 per person, up to 2 members per family per calendar year	When you visit network providers, you're covered at 100% of the allowable amount for most services after you meet your calendar year deductible, except for services with a specific dollar copayment.
Benefit	You Pay		Notes
	PPO	Non-PPO Deductible Plus
Office visits	$15 copayment	$15 copayment plus 20% of the allowance after deductable	Includes medication visits for mental illness.
Specialists	$25 copayment	$25 copayment plus 20% of the allowance after deductable
Emergency room care	$100 copayment	$100 copayment deductable does not apply	Copayment waived if you are admitted to the hospital within 24 hours. Coverage for accidents and life-threatening emergencies only.
Ambulance services	20% of the allowance	20% of the allowance. This benefit does not accumulate toward the annual out-of-pocket maximum deductable does not apply	Standard coverage under all group health plans will include municipal ambulance coverage for emergency transports. In addition to private ground ambulances municipal ground ambulance will be subject to the same contractual deductibles, copayments and coinsurance as private ground ambulance services. Coverage is limited to a maximum of $3,000 per occurrence for water and air ambulance.
Hospitalization	$0 after deductible	20% of the allowance after deductable	Unlimited days at general hospitals, up to 45 days per year at a specialty hospital.
Inpatient medical/surgical care	$0 after deductible	20% of the allowance after deductable	Unlimited days at general hospitals; up to 45 days per year at a specialty hospital.
Chiropractic physician	$15 copayment	$15 copayment plus 20% of the allowance after deductable	Chiropractic physician visits are limited to 12 visits per calendar year.
Outpatient medical/surgical care	$0 after deductible	20% of the allowance after deductable	Facility and doctor services, e.g. ambulatory surgi-centers and outpatient surgery.
Urgent care center	$50 copayment deductabl does not apply	$50 copayment plus 20% after deductable	Not all hospital based urgent care centers are in-network. Call ahead or contact Customer Service at (401) 831-6550 before you seek this kind of care.

Medical Care	You Pay		Notes
	PPO	Non-PPO Deductible Plus
Preventive and diagnostic lab tests, machine test and x-rays	$0 Deductable does not apply	20% of the allowance after deductable	The lab and x-ray facilities of some participating hospitals may not be considered in-network for all services. Call ahead or contact Customer Service at (401) 831-6550 before you seek this kind of care.
Colonoscopies and Sigmoidoscopies	$0	20% of the allowance after deductable
Prescription drugs	20% of the allowance for generic 25% of the allowance for preferred brand name drugs, 35% of the allowance for non-preferred brand name drugs.	20% of the Allowance for all drugs	Maximum $50.00 per prescription. Requires that mail services be utilized on all maintenance medications.
Mail order	20% of the allowance for generic 25% of the allowance for preferred brand name drugs, 35% of the allowance for non-preferred brand name drugs.	Requires that mail services be utilized or all maintenance medications. By using mail service, you will be able to to obtain up to a 90-day supply for the equivalent of two (2) retail copays.	A three month prescription (90 day) supply for the price of two months. $100 maximum copay on a (90 day) supply
Physical exams	$15 copayment	$15 copayment plus 20% after deductable	Pre-marital and pre-employment exams are not covered.
Pediatric preventive services	$15 copayment	$15 copayment plus 20% after deductable	Includes routine physicals, lab work and immunizations. For children born after January 1, 2001, a newborn program ID card will be issued in the child's name and no copayment will apply for wellness exams from birth to age 15 months.
Obstetrical care	$0 after deductible	20% of the allowance after deductable	Pre-natal visits, delivery and post-natal care. Office visit copayment of $15 will apply to the initial exam.
Gynecological care	$25 copayment	$25 copayment Plus 20% after deductable	Routine annual gynecological exams are covered with a $15 copay. All other Gynecological office visits are covered with a $25 copay. 100% coverage for annual pap tests and covered mammograms.
Eye exam (non-routine)	$25 copayment	$25 copayment plus 20% after deductable	If medically necessary. Other eye care benefits including coverage for routine annual vision exams and eyeglasses is provided through Davis Vision (See Section 7, Vision Care)
Behavioral Health (inpatient)	$0 after deductible	20% of the allowance after deductable	Preauthorization is strongly recommended (Behavioral and Chemical Dependency). Unlimited days per calendar year.
Behavioral Health (outpatient)	$15 copayment	$15 copayment plus 20% after deductable	Preauthorization is strongly recommended. Up to 30 visits per member per calendar year. Limit does not apply to medication visits.
Chemical Dependency (inpatient)	$0 after deductible	20% of the allowance after deductable	Preauthorization is strongly recommended (see Behavioral Health and Chemical Dependency). Detoxification: up to five admissions or 30 days in any calendar year, whichever comes first. Rehabilitation: up to 30 days in any calendar year for hospital or community residential care services.
Chemical Dependency (outpatient)	$15 copayment	$15 copayment plus 20% after deductable	Preauthorization is strongly recommended (see Behavioral Health and Chemical Dependency). Up to 30 hours per member per calendar year for facility based or office-based counseling.
Physical/occupational therapy	$0 (see notes) after deductible	20% of the allowance after deductable	With a hospital-based therapist and within 30 days following a hospital stay, home care program or ambulatory surgical procedure. Otherwise covered at 80% after deductible. Coinsurance, when applicable, does not accumulate toward the annual out-of-pocket maximum.
Durable medical equipment (DME)	$0 after deductible	20% of the allowance, this benefit does not accumulate toward the annual out-of-pocket maximum after deductable	Must be purchased at a participating DME vendor. Pharmacies do not participate in the DME network.
Private duty nursing	20% of the allowance after deductible	20% of the allowance after deductable	Preauthorization is strongly recommended. This benefit does not accumulate toward the annual out-of-pocket maximum.
Home health care and hospice care	$0 after deductible	20% of the allowance after deductable	Preauthorization is strongly recommended. Includes physician, nurse and home health aide visits.

Dental Care	You Pay		Notes
	Delta Dental PPO	Non-PPO
Annual deductible	$0	$0
Annual maximum	$2,000	$2,000	The Plan will pay up to $2,000 per person for dental care each calendar year.
Lifetime maximum	N/A	N/A	There is no cap on the amount the Plan will pay for dental care over each covered person's lifetime.
Orthodontic care maximum	$2,000	$2,000	The Plan will pay up to $2,000 for orthodontic care for each covered person.
Preventive/diagnostic/minor restorative	$0	The difference between non-PPO rate and Delta Dental's rate	Includes oral exams and cleanings, x-rays, simple extractions, fillings. For more detailed information, see Section 6, Dental Benefits.
Major restorative	$0	The difference between non-PPO rate and Delta Dental's rate	Includes extractions, general anesthesia, root canal and space maintainers.
Crowns	80% of the dental rate	80% plus the difference between non- PPO and Delta Dentals rate.
Periodontics	80% of the Delta Dental rate	80% plus the difference between non-PPO rate and Delta Dental's rate	All periodontic services require pretreatment estimates before the Plan will pay benefits. See Section 6, Dental Benefits for more information.
Implants	50% of the Delta Dental rate	50% plus the difference between non-PPO rate and Delta Dental's rate	All implants require pretreatment estimates before the Plan will pay benefits. Limited to once every five years. See Section 6, Dental Benefits for more information.
Prosthodontics	80% of the Delta Dental rate	80% plus the difference between non-PPO rate and Delta Dental's rate	All prosthodontic services (including bridges and partial and complete dentures) require pretreatment estimates before the Plan will pay benefits. See Section 6, Dental Benefits for more information.
Orthodontics	50% of the Delta Dental rate	50% plus the difference between non-PPO rate and Delta Dental's rate	All orthodontic (braces and related services) treatment requires a pretreatment estimate before the Plan will pay benefits. See Section 6, Dental Benefits for more information.

Vision Care
Every twelve months (to the day) you and/or your eligible dependents are entitled to one of the options listed below when you visit a Davis Vision provider:
Eye Exam	No copayment
Eye Exam + Eyeglasses	No copayment
Eye Exam + Two Pairs of Eyeglasses	$35 copayment
Eye Exam + Contact Lenses	$25 copayment
Eye Exam + Eyeglasses + Contact Lenses	$60 copayment

Hearing Care	You Pay		Notes
	Sargent Rehabilitation Center	Non-PPO
Exam	$0	Full cost	Once every 12 months. All benefits are payable only if you use the Sargent Rehabilitation Center. See Section 7, Hearing Care for more information.
Standard Hearing Aid or Programmable Hearing Aid	$0	Full cost	Hearing aids will not be replaced or provided more than once every 36 months. All benefits are payable only if you use the Sargent Rehabilitation Center.
Digital Hearing Aid	Balance remaining after a $1,000 benefit	Full cost	An allowance of $1,000 per aid for digital hearing aids. You are responsible for any remaining balance. All benefits are payable only if you use the Sargent Rehabilitation Center.
Follow-up visits	$0	Full cost	All benefits are payable only if you use the Sargent Rehabilitation Center.
Life Insurance
Employee	$50,000 benefit		Members do not have to pay for Life Insurance for themselves or their eligible dependents. See Section 8, Life Insurance for more information.
Spouse	$20,000 benefit		You must supply the Fund Office with a copy of the death certificate and marriage certificate to receive benefit.
Each dependent child	$20,000 benefit		Child must be at least 14 days old. You must supply the Fund Office with a copy of the death certificate to receive benefit.

Member Accidental Death and Dismemberment*
Benefits payable for the accidental death or dismemberment of a member only. See Section 8, Accidental Death and Dismemberment Benefits for more information.
Life	$50,000
Both hands
Both feet
Sight of both eyes
One hand and one foot
One hand and sight of one eye
One foot and sight of one eye
Speech and hearing
Quadriplegia
One hand	$25,000
One foot
Sight of one eye
Speech
Hearing
Paraplegia
Hemiplegia
Thumb and index finger of the same hand	$12,500
Dependent Accidental Death and Dismemberment *
Benefit payable for a dependent's accidental death or loss.
Life	$20,000
Both hands
Both feet
Sight of both eyes
One hand and one foot
One hand and sight of one eye
One foot and sight of one eye
Speech and hearing (by reason of Quadriplegia)
One hand	$10,000
One foot
Sight of one eye
Speech
Hearing
Paraplegia
Hemiplegia
Thumb and index finger of the same hand	$5,000
Weekly Accident and Sickness (Level I only)
Weekly benefit for up to 26 weeks	Up to $500 or 75% of weekly wages (not to exceed $500) Credit of 25 hours per week. See Section 8, Weekly Accident and Sickness for more information.

*Please refer to Section 8, Accidental Death and Dismemberment Benefits for members (or Section 8, Death and Dismemberment Benefits for Dependents) for detailed definitions of each dismemberment.

How Your Medical Plan Works

What is the "allowance"? The allowance is the amount that HealthMate Coast to Coast pays to a network provider for a particular service, or the amount HealthMate Coast to Coast will reimburse you if you use an out-of-network provider. You may be required to pay a percentage of the allowance (coinsurance) for certain services.

No one ever plans on getting sick or injured — but just in case — you should be familiar with the variety of Level I medical benefits that the Teamsters 251 Health Services Plan offers you and your family.

The Trustees have selected the Blue Cross Blue Shield "HealthMate Coast to Coast" network (BlueCard PPO) to provide high quality and convenient coverage including doctor's office visits, hospitalization and surgery, extended care, chemical dependency and behavioral health benefits. BlueCard PPO providers accept a pre-negotiated rate (allowance) for all services. In most cases you're only responsible for your coinsurance or a small copayment, if applicable.

 

If you're eligible for Level I benefits, you're covered by Blue Cross Blue Shield's "HealthMate Coast to Coast" network of physicians — the BlueCard PPO. Through the BlueCard PPO, personal physician office visits are just $15 and specialist office visits are just $25. HealthMate Coast to Coast offers unlimited days for most inpatient hospitalization. If you visit a provider who is not in the BlueCard PPO network, HealthMate Coast to Coast will generally reimburse you at 80% of the allowed amount. You will be responsible for paying the entire amount up front, and any balance that the non-network provider charges above the plan allowance, after you've met your annual deductible. HealthMate Coast to Coast has providers across the country so that you can receive care no matter where you live, work or travel.

What You Need To Do:

• What is Coinsurance? Coinsurance is a percentage of the allowance that you must pay for certain services under this program. If the allowance for a service is $100 and the Plan pays 80%, your coinsurance is the remaining 20% — so you must pay $20 for this service.

  Check your provider directory, call 1 (800) 810-BLUE, or visit the Web site at www.bcbsri.com to find a provider who participates in the BlueCard PPO.

• After you've received your medical care, the BlueCard PPO provider will forward the claim for processing.

Out-of-Network Service

You are not required to visit a doctor in the BlueCard PPO network; however, if you are treated by an out-of-network physician, you will pay more. You will be responsible for paying the entire cost up front, and then submitting your claim to Blue Cross Blue Shield of Rhode Island. They will generally reimburse you at 80% of the allowance for covered services. You'll also be responsible for any amount that the out-of-network provider charges above the HealthMate Coast to Coast allowance, as well as any applicable copayment. The example below shows the difference in out-of-pocket costs when you visit a provider in the BlueCard PPO or an out-of-network provider.

For example: Steven has to have surgery. HealthMate Coast to Coast has negotiated a discounted rate for services (the allowance) with BlueCard PPO providers. The allowance for Steven's surgery is $500.

HealthMate Coast to Coast BlueCard PPO	Non-Network Provider
The HealthMate Coast to Coast allowance for this surgery is $500	The Non-Network provider charges $600 for this surgery
HealthMate Coast to Coast pays 100% of the cost of the surgery. There is no copayment for surgery. *	HealthMate Coast to Coast pays 80% of the $500 allowance for this surgery — $400 *
	Steven must pay his 20% coinsurance — $100
	Steven is billed for the difference between the allowance and the non-network provider's charge — $100
The BlueCard PPO doctor files Steven's claim for him	Steven must file his own claim.
Steven's out-of-pocket cost — $0.	Steven's out-of-pocket cost — $200.

*In this example, the assumption is made that Steven has already met his annual deductible.

Out-of-pocket Maximum

The most you'll pay out of your own pocket for coinsurance each calendar year is $5,000 per individual. If you have family coverage, two family members must each meet the $5,000 maximum. Once you reach this maximum, HealthMate Coast to Coast will reimburse you for most eligible medical expenses at 100% of the allowance rather than 80%.

What's Not Covered

• Services that are not medically necessary
• Services covered by the government
• Benefits available from other sources
• Services or supplies mandated by laws in other states
• Services provided by college /school health facilities
• Services provided by facilities that haven't been approved by HealthMate Coast to Coast
• Services performed by people/facilities who are not legally qualified or licensed
• Eye Exercises
• Illegal drugs
• Employment related injuries
• Eyeglasses, routine eye exams, contact lenses, hearing aids or dental care (these are covered separately by the Plan, but not under the HealthMate Coast to Coast agreement)
• Deductibles, copayments or coinsurance

This is not a contract. A detailed list of exclusions and limitations appears in your HealthMate Coast to Coast Benefit Booklet.

Hospitalization and Surgery

HealthMate Coast to Coast provides coverage for you and your eligible dependents for hospitalization and surgery.

Hospitalization and Surgery are covered in full once your annual deductible has been met when you use a BlueCard PPO provider. No copayment applies. You must pay a $100 copayment for medically necessary care in an emergency room. If you're admitted to the hospital, this copayment will be waived.

Hospitalization Benefits

If you or your dependent(s) require treatment as an inpatient in a general hospital, your hospital stay is covered in full after you have met your deductible for an unlimited number of days. There is a 45-day per year limit for elective hospital stays in a specialty hospital. If you are hospitalized at a non-network hospital, you will be reimbursed at 80% of the allowance after you've met your deductible.

Preauthorization Recommended

You are strongly recommended to have any elective hospital stays and surgeries preauthorized. If you use a RI participating provider, your doctor will preauthorize your hospitalization for you. If you use a non-network provider or another Blue Cross Plan's Blue Card PPO provider, you must call (401) 459-5000 or 1 (800) 639-2227 for preauthorization. If you do not have an elective hospital stay preauthorized, services may not be covered.

Covered Hospital Expenses:

HealthMate Coast to Coast covers the following services if you are hospitalized:

• semi-private room or private room if medically necessary (network hospital only);
• medical and surgical supplies;
• use of the operating room;
• recovery room;
• anesthesia supplies;
• certain prescribed drugs and medications;
• laboratory examinations and pulmonary function tests;
• electrocardiograms (EKGs) and electro-encephalogram (EEG);
• insulin and shock therapy;
• inhalation and oxygen therapy;
• mammograms;
• pap smears;
• physical therapy;
• occupational therapy;
• speech evaluation and therapy;
• hearing evaluation;
• computerized axial tomography (CAT or CT scans) and magnetic resonance imaging (MRI);
• services of a licensed clinical psychologist when ordered by a doctor and billed by a hospital;
• blood services;
• diagnostic x-rays, radiotherapy and diagnostic and therapeutic radioisotopic services;
• hemodialysis — use of machine and other physical equipment;
• cardiac pacemakers;
• prosthesis;
• ultrasonography; and
• other hospital services necessary for your treatment and approved by Blue Cross Blue Shield of Rhode Island.

Emergency Room Care

Medically Necessary emergency room care is covered after you pay a $100 copayment. This copayment will be waived if you are admitted to the hospital within 24 hours. Only medically necessary emergency room services are covered, including treatment for accidents and life threatening illnesses.

Surgery

Out of Network Benefits If a non-network surgeon performs your surgery, you will be responsible for 20% of the cost after you've satisfied your annual deductible. A non-participating provider can bill you up to actual charge.

HealthMate Coast to Coast will cover most surgical procedures in full after your annual deductible has been met as long as:

• the doctor is a BlueCard PPO provider
• the operation is not experimental/investigational or cosmetic in nature;
• you have obtained preauthorization, if necessary;
• the operation is performed in a hospital, ambulatory surgi-center, doctor's office, or at home by a doctor; and
• the doctor is licensed to perform the surgery.

Multiple Surgeries

If you have two or more operations performed in the same area of the body, HealthMate Coast to Coast will only pay for the operation with the highest allowance. If you have two or more operations performed in different areas of the body (through separate incisions), HealthMate Coast to Coast will pay for the procedure with the highest allowance plus one-half of the allowance for the other procedure(s).

Anesthesia

This plan covers medically necessary anesthesia services received from an anesthesiologist when the services are related to a covered procedure. The allowance for the anesthesia service includes the anesthesia care during the procedure, time an anesthesiologist routinely spends with a patient in the recovery room, time spent preparing the patient for surgery, and for pre-operative consultations.

The allowance for the surgical procedure includes local anesthesia.

What's Not Covered

• Services if you leave the hospital or are discharged late
• Blood services
• Charges for administrative services
• Christian Scientist practitioners
• Cosmetic procedures
• Determination of post-operative fluid or electrolyte balance
• Removal of growths or lesions (reported cauterizations or electro fulguration methods used to remove growths)
• Research studies or fluoroscopy
• Supervision of Maintenance Therapy
• Autologus Bone Marrow transplants are covered for certain conditions refer to HealthMate Coast to Coast Subscriber Agreement.
• Experimental/investigational services

This is not a contract. A complete list of exclusions and limitations appears in your HealthMate Coast to Coast Benefit Booklet .

Wellness Benefits

Most wellness benefits, such as routine physical exams, annual gynecological exams and well-child office visits are covered for a $15 copayment when you use a BlueCard PPO provider.

Good Health Benefit

 

Well-Child Benefits

The Plan covers your dependent children for physical exams and immunizations. You are responsible for a copayment per doctor's office visit. However, if your child was born after January 1, 2001, a newborn program ID card will be issued in your child's name and there is NO copayment for wellness visits from birth to age 15 months.

The following chart shows the number of covered physical examinations your child may receive, based on age.

Wellness Benefits When you visit a HealthMate Coast to Coast BlueCard PPO provider, personal physician office visits are just $15. If you visit a non-network provider for wellness benefits, you must pay $15, PLUS 20% of the HealthMate Coast to Coast allowance and any amount your non-network provider charges above the allowance, after you meet your deductible.

Well-Woman Benefits

The Health Services Plan encourages women to have an annual wellness exam. Women are eligible for an annual exam for a $15 copayment when performed by a HealthMate Coast to Coast BlueCard PPO provider and a pap test which is covered in full.

Women are also eligible for one baseline mammogram between the ages of 35-39 and one every year at age 40 and after.

Woman's Health and Cancer Rights Act of 1998

In accordance with the Women's Health and Cancer Rights Act of 1998, this Plan will provide the following coverage for a participant who is receiving benefits in connection with a mastectomy and who elects breast reconstruction surgery in connection with such mastectomy:

• reconstruction of the breast on which the mastectomy has been performed;
• surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• prostheses and physical complications for all stages of the mastectomy, including lymphedemas.

Routine Physical Exams

Physical exams are covered as a regular personal physician office visit for a $15 copayment when you visit a HealthMate Coast to Coast BlueCard PPO provider.

What's Not Covered

• Premarital or pre-employment physicals
• Weight loss programs/procedures

This is not a contract. A complete list of exclusions and limitations appears in your HealthMate Coast to Coast Benefit Booklet.

Extended Care Benefits

If you or someone in your family requires extended care, such as Home Health Care, Hospice Care, or Skilled Nursing Facility Care, HealthMate Coast to Coast will pay the full cost for most services, when you use a BlueCard PPO provider.

It is strongly recommended that you receive preauthorization before receiving extended care benefits. If your Extended Care services are provided by a network provider or facility that participates directly with BCBSRI, the provider will call to preauthorize your treatment for you. If you visit non-participating providers or facilities, or providers or facilities that participate with another Blue Cross & Blue Shield network, we recommend that you call customer service to initiate the preauthorization process before scheduling the service. Preauthorized Hospice Care services are covered in full after your annual deductible has been met and there is no copayment when you use a BlueCard PPO provider.

Non-Network Extended Care Benefits If you use providers who do not participate in the HealthMate Coast to Coast BlueCard PPO network, HealthMate Coast to Coast will cover 80% of the allowable charge for covered services. You will be responsible for the other 20% as well as any amount the non-network provider charges over the allowable amount, after you've satisfied your deductible.

What You Need to Do:

• If you obtain extended care benefits from a non-network provider or facility, or a provider or facility that participates with another Blue Cross & Blue Shield network, contact HealthMate Coast to Coast at (401) 459-5000 or 1 (800) 639-2227 at least two days before you require care to receive preauthorization.

Home Health Care

If you or one of your eligible dependents qualify to receive health care at home, HealthMate Coast to Coast will cover the services provided through a hospital or approved community home health care program to treat your condition. The following services are covered in full after your annual deductible has been met when you use a HealthMate Coast to Coast BlueCard PPO provider:

• Visiting nurse services billed by a visiting nurse agency; and
• Services of a home health aide.
• Home Infusion therapy services.

Private Duty Nurses

Medically necessary services are covered when received in your home as part of an approved home care program. You will be responsible for 20% of the allowable charge after your annual deductible has been met for Private Duty Nurses. Refer to your HealthMate Coast to Coast Benefit Booklet for exclusions.

Hospice Care

If you have a terminal illness, you may be eligible for the following Hospice Care benefits:

• Services of a hospice coordinator billed by the hospice care program;
• Services of a visiting nurse when billed by a visiting nurse agency; and
• Services of a home health aide.

When Hospice Care is preauthorized and you use BlueCard PPO providers, Hospice Care services are covered in full after your annual deductible has been met and there is no copayment.

Skilled Nursing Facility

Care in a Skilled Nursing Facility is covered for you and your dependents if preauthorization is obtained and:

• The condition requires skilled nursing services, skilled rehabilitation services or skilled nursing observation;
• Services are required on a daily basis; and
• The care can only be provided in a skilled nursing facility where you are in inpatient.

What's Not Covered

• Homemaking services or services provided by relatives or members of your household.

This is not a contract. A complete list of exclusions and limitations appears in your HealthMate Coast to Coast Benefit Booklet.

Behavioral Health and Chemical Dependency

Through HealthMate Coast to Coast, you and your eligible dependents are eligible for treatment of behavioral health and chemical dependency. Your level of coverage depends on whether you receive treatment as an inpatient or as an outpatient, and whether you use a provider in or out of the BlueCard network. Remember, for both inpatient and out-of-network care, you must satisfy your deductible before HealthMate Coast to Coast will pay benefits.

It is strongly recommended that you obtain preauthorization from the Behavioral Health/Chemical Dependency Case Manager before you receive treatment. You may receive outpatient treatment for Behavioral Health and Chemical Dependency for a $15 copayment per visit.

What You Need To Do:

• Call HealthMate Coast to Coast at 1 (800) 810-BLUE or visit the Web Site at www.bcbsri.com to find a provider in the BlueCard PPO.
• If you receive out-of-network treatment from an out of state BlueCard provider, call 1 (401) 277-1344 to have a case manager preauthorize benefits. A participating Rhode Island PPO provider will obtain preauthorization for you.

How can I get preauthorization for treatment? If your provider participates in the Blue Cross Blue Shield of R.I. network, he or she will call the case manager for you. If you seek care from a provider who does not participate in the network or a provider who participates in another Blue Cross Plans Blue Card PPO network, you must call 1 (800) 274-2958 to have a case manager preauthorize your treatment. If you fail to call, you may be responsible for all charges deemed not to be medically necessary.

Behavioral Health Treatment

Inpatient

With preauthorization, your inpatient treatment is covered in full after your annual deductible has been met for unlimited days per calendar year when you use a provider in the BlueCard PPO.

If you seek treatment for behavioral health outside of the BlueCard PPO, you will be responsible for a 20% coinsurance, after you've met your deductible, as well as any amount your non-network provider charges over the HealthMate Coast to Coast allowance.

Outpatient

If you receive treatment for behavioral health from a BlueCard PPO provider, you will be covered for up to 30 visits per calendar year for a $15 copayment. For outpatient treatment from a non-network provider, you will be responsible for 20% of the allowance in addition to your copayment, after you've met your deductible, and any amount over the allowance that the non-network provider charges.

Chemical Dependency Treatment

Inpatient

HealthMate Coast to Coast will pay for your inpatient rehabilitation for up to 30 days per year after your annual deductible has been met. If you need inpatient treatment for detoxification, you will be covered for up to five admissions or 30 days per year, whichever comes first.

If your inpatient treatment is provided by a non-network provider, you must pay 20% of the cost after you've met your deductible, as well as any amount your provider charges over the HealthMate Coast to Coast allowance.

Outpatient

If your treatment for chemical dependency is provided on an outpatient basis, you will be covered for up to 30 hours per calendar year for a $15 copayment.

What's Not Covered

• Marital counseling
• Mental disorders and illnesses which, according to general medical standards, cannot be effectively treated
• Psychoanalysis for educational purposes
• Recreation therapy, non-medical self-care, or self-help training
• Smoking cessation
• Chemical dependency treatment in your home or in a doctor's office

This is not a contract. A complete list of exclusions and limitations appears in your HealthMate Coast to Coast Benefit Booklet.

Prescription Drug Benefits

The prescription drug benefit offers you and your family a convenient and inexpensive way to receive your covered prescription medication. Your responsible for your coinsurance.

You may choose to have your "non-maintenance" prescriptions filled by mail, at a pharmacy that participates in the network, or at a non-participating pharmacy. Your prescription drug program requires that mail services be utilized for all maintenance medications; however, you may receive two (2) (one orginal fill plus one refill) fills at your retail pharmacy prior to being required to use mail service. In order to determine if a medication you are taking is categorized as a “maintenance” medication, please call CVS/Caremark Customer Service at 1-888-543-5940.

Your prescription drug plan is administered through the CVS/Caremark. You pay coinsurance for prescription drugs if you get them through a participating network pharmacy or through the Direct Mail Service Program. You do not have to meet a deductible to receive this benefit. When you have your prescriptions filled through the Mail Service Program, you may order your refills by phone, mail or Internet.

What You Need To Do

• Find a participating Pharmacy near you. There is a comprehensive list of pharmacies that are part of the network.
• Take your CVS/Caremark ID card to the pharmacy with you.
• Pay the pharmacist your copayment when you pick up your prescription. There are no claim forms to file, and you do not have to meet a deductible to receive this benefit.
• To use the Mail Service Program, call Customer Service at 1-888-543-5940 to request a form and an envelope. (Mail order program is usually much less expensive)
• Mail your prescription and your coinsurance payment with your form in the envelope.

Generic Drugs Save You Money Remember that if you ask your physician to prescribe less expensive drug equivalents (generic drugs) you will pay less.

Covered Prescription Drugs

The following drugs are included as covered prescription drugs:

• Most medications that require a physician's prescription by federal law that are not available "over-the-counter;"
• Needles and syringes when dispensed with insulin;
• Oral contraceptives; and
• Injectable drugs.

Participating Pharmacies

When you fill a prescription at a pharmacy that participates in the prescription drug network, you just present your CVS/Caremark ID card when you request your medication. You’ll pay a copayment for the cost of the prescription.

More than 60,000 pharmacies participate in the network, including major chains like CVS, Brooks, Discount Pharmacy Place, Shaw's Supermarket/Star Market, Stop and Shop, Target Pharmacy, Walgreens and Wal-Mart as well as many independent pharmacies.  A list of participating pharmacies is listed on the next couple of pages.

Non-Participating Pharmacy

If you have your prescriptions filled at a pharmacy that does not participate in the network, you must pay the full amount of the prescription’s cost at the time of purchase. You will be reimbursed according to the CVS/Caremark maximum allowance, not the retail cost, minus 20% copayment. This means a higher out-of-pocket cost to you.

Mail Service Convenience After you've placed your first order through the Mail Service program, you can order your refills 24 hours a day, seven days a week, right from home. You can pay your copayment by check, money order or credit card, and shipping is free.

Mail Service Prescription Drugs

The Mail Service Program is required for you to receive “maintenance drugs” that you require on an on-going basis. Examples of maintenance drugs include those you take for high blood pressure, heart conditions or diabetes. Because you know in advance that you will need this medication, it’s easy to establish a routine of filling these prescriptions by mail.

How to use the Mail Service Program

• First call CVS/Caremark Direct at 888-543-5490 to request a mail service form and envelope. At that time, find out how much your copayment will be, so you can send payment with your order or provide credit card information. You may also order prescriptions on-line at www.pharmacare.com.
• Mail your original prescription along with your copayment (if you're paying by check or money order) to PharmaCare Direct, PO Box 9062, Clearwater, FL 33758-9748. Shipping is free.

You may order refills 24 hours a day, seven days a week by phone or mail.

What's Not Covered

• Over the counter drugs (even if prescribed)
• Experimental drugs
• Biological products for immunizations
• Needles and syringes other than for use with insulin
• Drugs used for cosmetic purposes
• Viagra or any therapeutic equivalents
• Medications that are administered while you are a patient in a hospital, rest home, sanitarium, nursing home, home care program, or other institution that provides prescription drugs as part of its services or that operates a facility for dispensing prescription drugs
• Drugs that do not have FDA approval or that have been placed on notice of opportunity hearing status by the Federal DESI Commission
• More than two treatments per lifetime of the following:
• Smoking cessation drugs, Nicotine Transdermal Patch or
• Nicotine Chewing Gum.

National and Regional Pharmacy Chains in CVS/Caremark National Network

A & P U.S. ACCESSHEALTH ACCESSHEALTH POWERPLUS NTWK ALBERTSONS AFFILIATES ACME PHCY (OHIO) ALBERTSONS ALBERTSONS LLC/CEREBUS ALLCARE/MALONE'S PHARMACY ALLINA COMMUNITY PHARMACY ALLSCRIPTS AMERICAN PHARMACY COOP AMERIDRUG AMERISOURCE BERGEN APPALACHIAN REGIONAL HEALTHCARE ARBOR DRUGS (CVS) ASTRUP DRUG ATLAS DRUGS AURORA PHARMACY BALLS FOUR B CORP (PRICE CHOPPER/HEN HOUSE) BARTELL DRUG BAYSTATE PHARMACY BIG "A" DRUG STORES BIG Y FOODS BI-LO, LLC BIOSCRIP PHARMACY dba BIOSCRIP PHARMACY BROOKS PHARMACY BROOKSHIRE BROTHERS PHARMACY BROOKSHIRE GROCERY BRUNO'S PHARMACY BUEHLER FOOD MARKETS BUEHLER'S PHARMACY BUFFALO PHARMACY CARE PHARMACY (IND) CAREMARK THERAPEUTIC SVCS CARLE RX EXPRESS PHARMACY CARRS QUALITY CTRS (SAFEWAY) CBC PROFESSIONAL PHARMACY CITY MARKET (AFF.-KROGER) COBORNS / CASHWISE COLUMBUS HEALTH SVCS COMMUNITY DIST dba DRUG FAIR COMMUNITY PHCIES LP COSTCO PHARMACY CRESCENT HEALTHCARE (HOME INFUSION) CURASCRIPT PHARMACY CVS PHARMACY DAHL'S FOODS DALLAS METROCARE SERVICES DAVIDSON DRUGS DEPT OF VA AFFAIRS DIERBERG FAMILY MARKETS DILLON'S PHARMACY (AFF.-KROGER) DISCOUNT DRUG MART DOC'S DRUGS DOMINICK'S/OMNI (SAFEWAY) DRUG WORLD PHARMACY DUANE READE DULUTH CLINIC EATON APOTHECARY ECKERD DRUG EPIC PHARMACY NTWK (IND) FAGEN PHARMACY FAIRVIEW PHCY SVCS, LLC FAMILYCARE NTWK (IND) FAMILYCARE PLUS (IND) FAMILYMEDS (ARROW CORP) FARM FRESH FELPAUSCH PHARMACY FOOD LION PHARMACY FRED MEYER (AFF.-KROGER) FRED'S PHARMACY - AR FRED'S PHARMACY - TN FRUTH PHARMACY FRY'S FOOD & DRUG (AFF.-KROGER) GEMMEL PHCY GROUP GENUARDI'S PHCY (SAFEWAY) GERIMED (LTC FACILITIES) GIANT EAGLE GIANT FOOD STORES. LLC (CARLISLE, PA)(AHOLD) GIANT OF MARYLAND, LLC (GIANT PHCY)(AHOLD) GRISTEDES PHARMACY GROUP HEALTH ASSOCIATES GU MARKETS, LLC H.E.B. FOOD & DRUGS HAGGEN HANNAFORD BROTHERS dba SHOP N' SAVE HAPPY HARRY'S (WALGREENS) HARP'S FOOD STORES HARRIS TEETER HEALTHPARTNERS HENRY FORD HEALTH SYSTEM PHCY HIP HEALTH PLAN OF NEW YORK HI-SCHOOL PHARMACY HOMELAND PHARMACY HORTON & CONVERSE HY-VEE INGLES MARKETS INTEGRITY HEALTHCARE SVCS INTERMOUNTAIN HEALTH CARE J.H. HARVEY CO, LLC KASH N' KARRY FOOD STORES KELSEY-SEYBOLD KERR DRUG KINDRED PHARMACY SVCS KING KULLEN PHARMACY KING SOOPERS (AFF.-KROGER) KINNEY DRUGS KLEINS PHARMACY KLINGENSMITH'S DRUG STORES K-MART CORP. KNIGHT DRUGS KOHLL'S PHCY & HOMECARE KOPP DRUG KROGER PHCY K-VA-T FOOD STORES dba FOOD CITY PHCY LEADER DRUG STORES (IND) LIFECHEK DRUG LONGS DRUG STORES LOUIS & CLARK DRUG LOVELACE SANDIA HEALTH SYSTEM M.K.STORES MAJOR VALUE PHCY NTWK MANAGED PHARMACY CARE (IND) MARC GLASSMAN MARKET BASKET PHCIES MARSH DRUGS, LLC MARSHFIELD CLINIC PHARMACY MARTIN'S SUPER MARKETS MAXOR PHARMACY MAY'S DRUG STORES MED-FAST PHARMACY MEDICAP MEDICINE CTR OF ATLANTA dba TRACEY'S MEDICINE CTR MEDICINE SHOPPE MEDI-SERV MED-X CORP dba DRUG MART MEIJER PHARMACY MEMORIAL SLOAN KETTERING MENDOTA HEALTHCARE MERCY HEALTH SYSTEM RETAIL PHCIES MOORE & KING PHCY MORTON DRUG NASH FINCH CO/ERICKSONS NAVARRO DISCOUNT PHCIES NCS HEALTHCARE/OMNICARE NEIGHBORCARE LTC PHCIES NEIGHBORCARE PROFESSIONAL LTC PHCY SVCS NEIGHBORCARE PROFESSIONAL PHCY SVCS NORTHEAST PHARMACY NORTHWEST HEALTH VENTURES-LEHMAN NOVA FACTOR OAKWOOD PHARMACY ONCOLOGY PHARMACY SERVICES OWL DRUG STORES P & C FOOD MARKET (PENN TRAFFIC) PACMED CLINIC PHCIES PAMIDA PHARMACY PARK NICOLLET PHCIES PATHMARK STORES PAVILLION PLAZA PHCIES PEOPLES PHARMACY PHARMA-CARD PHARMACARE PHCY/PHARMACARE SPECIALTY PHCY PHARMACARE SPECIALTY PHCIES & CVS PROCARE PHARMACY EXPRESS SERVICES PHARMACY PLUS PHARMACY PROVIDERS OF OKLAHOMA PHARMERICA PIGGLY WIGGLY CAROLINA CO (PRICE WISE) PRAIRIESTONE PHARMACY PRICE CHOPPER/GOLUB CORP PUBLIX SUPER MARKETS QFC PHARMACIES (AFF.-KROGER) QUALITY MARKETS (PENN TRAFFIC) QUICK CHEK FOOD STORES RALEY'S DRUG CENTER/BEL AIR RALPH'S PHCIES (AFF.-KROGER) RANDALL'S PHCY (SAFEWAY) RECEPT PHARMACY REVCO DRUG STORES (CVS) RINDERER'S DRUG STORES RISCH DRUG STORES RITE AID CORP RIVERSIDE DIV OF PENN TRAFFIC (BI-LO) RPCS RXD PHARMACY RXPRIDE SAFEWAY SAVE MART SUPERMARKETS SAV-MOR DRUG STORES SCHNUCK'S PHARMACY SCOLARI'S PHARMACY SCOTT & WHITE SEAWAY FOOD TOWN SEDANO'S PHARMACY SEDELL'S PHARMACY SHOPKO STORE SHOPRITE PHARMACY (WAKEFERN) SMITH'S FOOD & DRUG CENTERS (AFF.-KROGER) SOUTHERN FAMILY MARKETS LLC SPARTEN RETAIL (FAMILY FARE/GLENS PHCY) ST JOHN HEALTH SYSTEM ST JOSEPH MERCY PHCY STAR MARKETS / SHAWS PHCY (ALBERSTONS) SUPER D DRUGS SUPERMARKET INVESTORS (HARVEST FOODS) SUPERVALU PHARMACIES / KELTSCH TARGET STORES THE PAY-LESS PHCY GROUP THE STOP & SHOP SUPERMARKET CO, LLC (AHOLD) THIRD PARTY STATION THRIFTY-WHITE STORES TIMES SUPERMARKET TOM THUMB FOOD & PHCY (SAFEWAY) TRINET (FORMERLY TRUECARE) TWIN KNOLLS PHCIES UKROPS SUPERMARKET PHCY UNITED DRUGS (IND) UNITED SUPERMARKETS UNITY RETAIL PHARMACIES UNIVERSITY OF UTAH HEALTH UNIVERSITY HEALTH SYSTEMS PHCIES US BIOSERVICES USA DRUG USA DRUG / M & H DRUGS U-SAVE PHCY UW HEALTH OUTPATIENT PHARMACY VALU MERCHANDISERS / A W G NTWK VONS PHCY (SAFEWAY) WALGREENS DRUG STORES WAL-MART WALT'S PHARMACY WAYNE-OAKLAND PHCY MGMT WEBER & JUDD KAHLER WEGMANS FOOD MARKETS WEIS PHARMACY WESTERN DRUG DISTRIB dba DRUG EMPORUIM WINN DIXIE STORES YOKE'S WASHINGTON FOODS

What is Medical Necessity Review? HealthMate Coast to Coast reviews whether a health care service is medically necessary to treat your illness or injury for the purpose of paying your claims. If treatment or services that require a review are not considered medically necessary, HealthMate Coast to Coast reserves the right to refuse payment.