Teamsters Local 251 Health Services & Insurance Plan

Summary of Benefits

The Teamsters Local 251 Health Services and Insurance Plan offers you and your family a comprehensive package of benefits. Your coverage includes Medical, Prescription Drug, Dental, Legal, and MAP.

The Trustees have chosen the Blue Cross Blue Shield HealthMate Coast to Coast Cooption Plan to provide you with quality medical care and Pharmacare for your prescription drug plan. Through Blue Cross Blue Shield, you also get the convenience and cost, 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 II benefits. 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
Benefit	PPO	Non-PPO	Notes
Annual Out-of-Pocket Maximum	$2,000 per person $4,000 per family (2 family members must seperately meet $2,000.	$4,000 per Person $8,000 per Family (2 family members must seperately meet $4,000.	If your copayments exceed the annual out-of-pocket maximum, the Plan will increase your coverage for most services 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	$500 per person, up to 2 members per family	$500 per person, up to 2 members per family	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
Benefit	PPO	Non-PPO Deductible Plus	Notes
Office visits	$15 copayment	$15 copayment plus 30% of the allowance after deductable	Includes routine and non-routine physicals, pediatric immunizations, and routine gynecological exams.
Specialists	$25 copayment	$25 copayment plus 30% of the allowance after deductable
Emergency room care	$100 copayment deductable does not apply	$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	30% of the allowance. This does not accumulate toward the annual out-of-pocket maximum	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	10% of the allowance after deductible	30% of the allowance after deductable	Unlimited days at general hospitals, up to 45 days per year at Inpatient Rehabilitation Facility.
Inpatient medical/surgical care	10% of allowance after deductible	30% of the allowance	Unlimited days at general hospitals; up to 45 days per year at an Inpatient Rehabilitation Facility.
Chiropractic physician	$25 copayment	$25 copayment plus 30% of the allowance after deductable	Chiropractic physician visits are limited to 12 visits per calendar year.
Outpatient medical/surgical care	10% of allowance after deductible	30% of the allowance	Facility and doctor services, e.g. ambulatory surgi-centers and outpatient surgery.
Walk-in treatment centers	$50 copayment after deductable	$50 copayment plus 20% after deductable	Not all hospital based walk-in treatment centers are in-network. Call ahead or contact Customer Service at (401) 459-5000 before you seek this kind of care.

Medical Care	You Pay		Notes
Medical Care	PPO	Non-PPO Deductible Plus	Notes
Preventive and diagnostic lab tests and x-rays	$0	30% of the allowance deductable does not apply	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) 459-5000 before you seek this kind of care.
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 service 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 30% after deductable	Pre-marital and pre-employment exams are not covered.
Pediatric preventive services	$15 copayment	$15 copayment plus 30% 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	10% of the allowance after deductible	30% 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 30% 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 30% after deductable	If medically necessary.
*Behavioral Health (inpatient)	10% of allowance after deductible	30% of the allowance after deductable	Preauthorization is strongly recommended (Behavioral and Chemical Dependency). Unlimited days per calendar year.
*Behavioral Health (outpatient)	$25 copayment	$25 copayment plus 30% 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)	10% of the allowance after deductibleafter deductable	30% 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)	$25 copayment	$25 copayment plus 30% 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	10% of the allowance after deductible	30% of the allowance
Durable medical equipment (DME)	10% of the allowance after deductible	30% 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	10% of the allowance after deductible	30% 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	10% of the allowance after deductible	30% of the allowance after deductable	Preauthorization is strongly recommended. Includes physician, nurse and home health aide visits and home infusion therapy.

* Please note: Benefits are subject to change if pending Federal parity legislation is enacted into law.

Dental Care	You Pay		Notes
Dental Care	Delta Dental PPO	Non-PPO	Notes
Annual deductible	$0	$0
Annual maximum	$1,800	$1,800	The Plan will pay up to $1800 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 $2000 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.

How Your Medical Plan Works

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

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.

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 II 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 70% 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 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 70%, your coinsurance is the remaining 30% — so you must pay $30 for this service.

What You Need To Do:

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 70% 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 90% of the $500 allowance for the surgery — $450.	HealthMate Coast to Coast pays 70% of the $500 allowance for this surgery — $350
Steven must pay his 10% coinsurance — $50.	Steven must pay his 30% coinsurance — $150
	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 — $50 plus the annual deductible.	Steven's out-of-pocket cost — $250 plus the annual deductible.

Out-of-pocket Maximum

The most you'll pay out of your own pocket for coinsurance each calendar year is $2,000 per individual at network providers/$4,000 per individual at non-network providers. If you have family coverage, two family members must each meet the individual maximum. Once you reach this maximum, HealthMate Coast to Coast will reimburse you for most eligible medical expenses at 100% of the allowance for the remainder of the year.

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
Pre-authorization penalties, deductibles, copayments or coinsurance

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

Hospitalization and Surgery

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

Hospitalization and Surgery are covered at 90% of the allowance 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 eligible dependent(s) require treatment as an inpatient in a general hospital, your hospital stay is covered up to 90% of the allowance after you have met your deductible for an unlimited number of days. There is a 45-day per year limit for elective inpatient stays in a rehabilitation facility. If you are hospitalized at a non-network hospital, you will be reimbursed at 70% 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 30% 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 at 90% of the allowance after your annual deductible has been met as long as:

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

HealthMate Coast to Coast covers general and local anesthesia when required. The general anesthesia benefit includes time an anesthesiologist routinely spends with a patient in the recovery room and for pre-operative consultation. Office visits or office consultation to anesthesiologists are limited to two per calendar year and subject to the $25 specialist office visit copayment.

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 Subscriber Agreement.

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.

Well-Child Benefits

The Plan covers your dependent children for physical exams and immunizations. You are responsible for a $15 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.

Age	Number of Physical Exams Covered
Birth through 15 months	8
16 months through 35 months	3
36 months through 19 years	1 per year

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 30% 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. Premarital or pre-employment examinations are not covered.

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 Subscriber Agreement.

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 up to 90% of allowance 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 up to 90% of allowance after your annual deductible has been met 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 70% of the allowable charge for covered services. You will be responsible for the other 30% 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 up to 90% of allowance 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

Services are covered when received in your home as part of an approved home care program medically necessary. Within the BlueCard PPO network, you will be responsible for 10% of the allowable charge after your annual deductible has been met for Private Duty Nurses. Refer to your HealthMate Coast to Coast Subscriber Agreement 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 up to 90% of allowance after your annual deductible has been met.

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 Subscriber Agreement.

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 can receive treatment.
You may receive outpatient treatment for Behavioral Health and Chemical Dependency for a $25 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 (800) 274-2958 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 up to 90% of allowance 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 30% 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 $25 copayment. For outpatient treatment from a non-network provider, you will be responsible for 30% 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. 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 30% 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 $25 copayment. For outpatient treatment from a non-network provider, you will be responsible for 30% 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.

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 Subscriber Agreement.

Prescription Drug Benefits

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

You are required to have maintenance prescription filled by mail.

our prescription drug plan is administered through 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. Please see detailed list.
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 (888)543-5490 to request a form and an envelope.
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 prescription 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, Walgreens, Rite Aid and independent pharmacies.

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 the purchase. You will be reimbursed according to the CVS/Caremark maximum allowance, not the retail cost, minus your 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

You are required to have your maintenance prescriptions filled by mail.

How to use the Mail Service Program

First call CVS/Caremark Direct at 1-888-543-5490 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.caremark.com.
Mail your original prescription along with your copayment (if your paying by check or money order) to CVS/Caremark, PO Box 65954, San Antonio, TX 78265. 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
Smoking cessation drugs, aids or programs, whether prescribed or not
More than one of the following per lifetime:
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

Other Covered Medical Expenses

Through HealthMate Coast to Coast, the Plan offers additional medical benefits such as chiropractic treatment, the rental or purchase of durable medical equipment, and maternity benefits.

Chiropractic Physician Care

You and your family members are eligible for 12 office visits/treatments for chiropractic services each calendar year when you visit a HealthMate Coast to Coast BlueCard PPO provider. You are responsible for a $25 copayment per visit. If you choose a visit a non-participating provider the $25 copayment, a 30% coinsurance and your annual deductible will apply.

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.

Durable Medical Equipment

HealthMate Coast to Coast will cover Durable Medical Equipment at 90% of the allowance after you have met your annual deductible when you visit a HealthMate Coast to Coast BlueCard PPO provider. If you choose to visit a non-participating provider a 30% coinsurance and deductible will apply. The following equipment is covered, subject to medical necessity review:

Rental or purchase, whichever is cheaper for wheelchairs, hospital beds and other durable medical equipment used only for medical treatment.
Replacement of equipment you own that is required due to a change in your medical condition.
Therapeutic/molded shoes for the prevention of amputation for the treatment of diabetes (two
pairs of shoes or four individual shoes per calendar year).