Free Motion to Certify Class - District Court of Arizona - Arizona

,_ Health and wellness
Health care benefnts
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l Figure 3.2
{ Note: You do not have to use Blue Cross Blue Shreld providers rf you are enrolled ln one of these non-network (indemnity) plans However, if
` you do use Blue Cross Blue Shreld preferred provlders, you can take advantage of the providers negotrated rates for network members and
U reduce your out-of—pocket expenses
1 Non-network plan summaries
Type of service or supply Blue Cross Blue Shield Blue Cross Blue Shield
_ Out-of-Area Indemnity Plan High Deductible Plan
` Lifetime maximum Unlrmlted Unlimited
_ l Precertlflcatlon
Precertlflcatlon required for all Inpatient Must precertrfy· Hospital admrsslons — Must precertrfy Hospital admissions ——
i admissions and some other services. $500 penalty per occurrence if not $500 penalty per occurrence if not
T See Figure 3.2.1 for each plan’s list of precertlned, other services may not be precertrfled; other servrces may not be
~ precertlftcatlon requirements. covered lf not preoertlfied covered sf not precertrfled _
I Extended family benefits
r _ Domestic partner (same or opposite sex) Yes Yes __
Other adult dependent Yes Yes
T Calendar year deductible
Per person $300 $1,500
Per family $600 $3.000
l Out-of-pocket maximum
l Per person $2,000 $5,000 __
' Per family $4,000 $10.000
S Primary and preventive care
` Physician office visits 80% after deductlble 80% after deductible
= Offlce surgery 80% after deductible 80% after deductrble
Preventive examinations 100%, frequency of covered exam according 80%; frequency of covered exam according
, to health plan schedule to health plan schedule, subject to a $250
L per person annual maximum for combrned
C wellness services (not subject to deductible)
f Preventive child and well-baby care 100%, frequency of covered exam accordrng Covered as part of preventive exam benefit
, I to health plan schedule
1 lmmunlzatrons 100%, frequency of covered rmmumzatlon Covered as part of preventive exam benefit
I E according to health plan schedule
Well—woman exam 100%; frequency of covered exam according Covered as pan of preventive exam benefit
. l , to health plan schedule
` Preventive mammogram 100% (one annual preventrve mammogram for Covered as part of preventive exam benefit
l women ae 35 and over, coverage available (one annual preventive mammogram for
i pnor to age 35 rf medically necessary) women age 35 and over, coverage available
i ’ prlor to age 35 lf medically necessary)
if Preventive lab and X—ray 80% after deductible Covered as part of preventrve exam benefit
Primary and preventive care (exclusrons and lrmrtatlons)
gilt Preventive eye examinations Not covered. routrne vrsron care avaalable Not covered, routine vision care avaliable
lil; through Bank of America vrslon care plans through Bank of Amerrca vlsron care plans
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· Case 2.03-cv—02262—ROS Document 158-42 Filed 10/07/20 age 1 of 1

Case 2:03-cv-02262-ROS

Document 158-42

Filed 10/07/2005

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