Group Quote Request Form (group size 51+) /
Broker name / Broker number / Date submitted / Requested effectice date
Type
New Change Reinstatement / Current carrier / Association / Type of industry / Rates
Composite Age/Sex
Broker fax no. / Broker phone no. / Broker e-mail / Group name / Group no.
Group contact name / Group phone no. / Group address / City, State, ZIP code / SIC Code
Blue Preferred® HMO Cost Share Options
Physician
Home and
Office
Services
PCP/SCP / Deductible
Single/
Family / Inpatient
Facility / Outpatient
Surgery:
Hospital/
Alternative
Care
Facility / Other
Outpatient
Services* / Inpatient/
Outpatient
Professional
Services / Out-of-Pocket
Limit
Single/
Family / Emergency
Room
Services
@ Hospital / Prescription
Drug Option
Option 1 / $10/$15 / $100/$300 / $250 / $75 / 10% / 10% / $1,000/$2,000 / $150/10% / G, H, I
Option 2 / $15/$30 / $250/$750 / 10% / 10% / 10% / 10% / $1,500/$3,000 / $150/10% / G, H, I
Option 3 / $15/$30 / $250/$750 / 20% / 20% / 20% / 20% / $2,000/$4,000 / $150/20% / G, H, I
Option 4 / $20/$35 / $500/$1,500 / 10% / 10% / 10% / 10% / $2,000/$4,000 / $150/10% / G, H, I
Option 5 / $20/$35 / $500/$1,500 / 20% / 20% / 20% / 20% / $2,000/$4,000 / $150/20% / G, H, I

Additional copayments, coinsurance and limits apply and may vary by option selected. Refer to the benefit summary for detailed information.

Notes:

Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance. However, the deductible does not apply to Emergency Room Services where a copayment and a percentage (%)
copayment applies.

Physician Home and Office Services exclude certain diagnostic tests such as MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, non-maternity related Ultrasounds and Allergy Testing.

All Mammograms (routine or non-routine),Diabetic Self Management Training, and Medical Nutritional Therapy in an Outpatient Facility are paid at the Physician Home and Office Services PCP copayment.

Allergy injections  $5 copayment

Specialist (SCP) copayment is applicable to all Specialists (excludes: General Physicians, Internists, Pediatricians, OB/Gyns, Geriatrics, Chiropractors or any other Network provider as allowed by the plan).

Urgent Care Facility $50 copayment.

Childhood immunizations (Network) – No Cost Share up to the maximum allowable amount.

*Other Outpatient Services include, but are not limited to, Allergy Testing, Physical Medicine Therapy through Day Rehabilitation programs, Ambulance Service, DME, Home Care Services (including Private Duty
Nursing), Hospice Care, MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies and Ultrasounds.

This benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

Group Name:
Prescription Drug
Prescription
Drug Option / Network
Retail / Network
Mail Service
G / $10/$20/$30* / $20/$40/$60*
H / $10/$25/$40* / $20/$65/$100*
I / $10/$30/$60* / $20/$75/$150*
*Member may be responsible for additional cost when not selecting the available generic drug. / Rx Notes:
  • Cost share structure equals tier 1/tier 2/tier 3.
  • 30-day supply for Network pharmacy (does not include drugs obtained through mail service pharmacy).
  • Certain diabetic and asthmatic supplies, excluding test strips, have no deductible/copayment/coinsurance up to
    the maximum allowable amount at Network pharmacies. Diabetic test strips paid same as any other drug (Network).
Anthem Rx Mail Service:
  • 90-day supply

All Health Options include the following (except as noted):
  • All medical deductible(s) and percentage (%) coinsurance apply toward the out-of-pocket limit
    (excluding flat dollar copayments).
  • $5 million lifetime maximum for all covered medical services. However, once the medical lifetime maximum is met,
    no additional prescription drug claims will be paid.
  • Benefit period = calendar year.
Skilled Nursing Facility:
Limited to 30 days per admission.
Home Care Services:
Limited to 90 visits per calendar year (excludes Private Duty Nursing).
Private Duty Nursing – limited to $50,000 annually with a lifetime maximum of $100,000.
Durable Medical Equipment and Orthotics:
Subject to benefit maximum of $4,000 per calendar year (excluding Prosthetic Devices and Medical Supplies).
Prosthetic Devices -- $4,000 limit per calendar year.
Physical Medicine and Rehabilitation:
Limited to 60 days per calendar year, includes Day Rehabilitation programs. / Outpatient Therapy:
Physical Therapy: 20 visits
Occupational Therapy: 20 visits
Speech Therapy: 20 visits
Behavioral Health Services:
Mental Health/Substance Abuse:
Inpatient: 20 days
Outpatient: 20 visits
Transitional Care Services: 15 visits
Human Organ and Tissue Transplants:
No deductible/copayment/coinsurance up to the maximum allowable amount during the Transplant Benefit Period.
Kidney Disease Treatment:
$30,000 calendar year maximum and applies toward the medical lifetime maximum. Cornea transplants are paid the same as any other medical covered benefit.
100+group size only:
Dependent Eligibility
End of
Calendar Year /
End of
Month /
To
Birthday
Age 18; 23, federal tax exemption(ASO only)
Age 19
Age 19; 21,full-time student
Age 19; 23,full-time student
Age 19; 24,full-time student
Age 19; 25,full-time student
Note: Bolded text is the standard Dependent Eligibility.
Refer to the 51+ Specialty CSOS for life and dental information. / Medicare Rx Option
Wrap
Subsidy*
Waiver
*Subsidy is only available to 100+ size groups
/
WI_Blue3.1_HMO_51+_R3_09 / Compcare Health Services Insurance Corporation (“Compcare”) underwrites the HMO policies; An independent licensee of the Blue Cross and Blue Shield Association.
®Registered marks Blue Cross and Blue Shield Association.