Children's Coverage

In this age of high medical costs, parents cannot afford to be without health care protection for their children. You may have health care coverage at work, but what about your children? In many cases, TRH Premier Children's coverage is less expensive than opting for family coverage with your employer.

That’s why TRH is offering an individual health care plan for unmarried, dependent children under the age of 18. The TRH Premier Children's coverage offers a $15 office visit copayment, prescription drug coverage, benefits for well child visits, and more.

Claims for TRH Premier Children's coverage are administered by BlueCross BlueShield of Tennessee. This coverage utilizes the Blue Network P with over 21,000 providers. These providers have agreed to discounted pricing arrangements to help maintain affordable rates.

• What’s Covered
• Benefit Schedule
• Copayment Guidelines
  
• Well Child Care
• Prescription Coverage
• Provider Directory
• Plan Exclusions

What's Covered?

• Well child care and immunizations
• Hospital services - inpatient and outpatient
• Physicians services - inpatient and outpatient
• Emergency Services
• Prescription Drug Coverage (no annual dollar limit)
• Diagnostic Services
• Ambulance Service (ground and air)
• Diabetes treatment, equipment, supplies and education
• Durable medical equipment and supplies
• Home Health Care
• Behavioral health care services (inpatient and outpatient)

Benefit Schedule
You can choose from three deductibles - $300, $500, or $1,000.

$300 Deductible

Network Providers Out-of-Network Providers
Deductible	$300
Emergency Room (Deductible Each Visit)	$25 $25
Office Visit Copayment	$15 N/A
Benefit Percentage	80% 60%
Out-of-Pocket Maximum	$2,400 Unlimited
Behavioral Health Care Coinsurance Behavioral Health Care Annual Maximum Behavioral Health Care Lifetime Maximum	50% 50% $7,500 $30,000
Lifetime Maximum	$2,000,000

$500 Deductible

Network Providers Out-of-Network Providers
Deductible	$500
Emergency Room (Deductible Each Visit)	$25 $25
Office Visit Copayment	$15 N/A
Benefit Percentage	80% 60%
Out-of-Pocket Maximum	$4,000 Unlimited
Behavioral Health Care Coinsurance Behavioral Health Care Annual Maximum Behavioral Health Care Lifetime Maximum	50% 50% $7,500 $30,000
Lifetime Maximum	$2,000,000

$1000 Deductible

Network Providers Out-0f-Network Providers
Deductible	$1,000
Emergency Room (Deductible Each Visit)	$25 $25
Office Visit Copayment	$15 N/A
Benefit Percentage	80% 60%
Out-of-Pocket Maximum	$5,000 Unlimited
Behavioral Health Care Coinsurance Behavioral Health Care Annual Maximum Behavioral Health Care Lifetime Maximum	50% 50% $7,500 $30,000
Lifetime Maximum	$2,000,000

Copayment Guidelines
The $15 copayment will be applied to each office visit for the eligible services performed in the office and provided and billed by a physician who is a network provider. The remaining charges for eligible services will be paid at 100 percent of the maximum allowable charge. If a physician who is an out-of-network provider is utilized for eligible services, benefits will be determined on the basis of the out-of-network deductible and coinsurance after deductible is met. Your liability will increase significantly when an out-of-network physician is utilized. Copayments do not apply toward satisfying deductibles, out-of-pocket, or maximum lifetime amount. Once the deductible and out-of-pocket are met, the copayments still apply.

Copayments do not apply to the following services: MRIs, MRAs, CAT scans, PET scans, DME and DME supplies, mammography, Synagis injections, nuclear medicine, bone density testing, cardiac diagnostic testing, growth hormone injections, diagnostic services sent out, surgery (and related surgical supplies) performed in the Physician’s office, Lupron injections, chemotherapy services, IV therapy, allergy testing and injections, Behavioral Health Care services, physical therapy services, ultrasound, dental services, orthotics, prosthetics, provider administered specialty pharmacy products, nerve conduction tests, neuropsychological and neurological tests, biopsy interpretations, and chiropractic services. They will be covered under normal contract benefits, subject to the terms and conditions of the EOC. Deductibles and Coinsurance will apply.

Well Child Care
Well child physical exams and immunizations are covered for members under the age of seven (7) subject to the following guidelines:

• Under age 1: four exams before the child’s first birthday
• Age 1: two exams before the child’s second birthday
• Age 2 - 6: one exam per year (The child’s birthday determines when a year begins and ends.)
• Physical Examinations
• Immunizations/vaccinations/booster shots
• You must use a network provider for this service to be covered

Prescription Drug Coverage
Benefits are available for prescription drugs subject to the deductible and coinsurance. There is an extensive pharmacy network. These pharmacies have agreed to special pricing arrangements for TRH members. Failure to use a network pharmacy may cost you more money.

When you go to a participating pharmacy, show your TRH member identification card along with your prescription order. The pharmacy will give you an authorization number. You will use this number when filing your prescription claims. You should file your prescription claims by mailing them to BlueCross BlueShield of Tennessee. Claim forms are available by contacting us or from your local Farm Bureau office or click here to download a form.

You will be reimbursed the network provider coinsurance percentage after the deductible has been met. If you use a pharmacy that is out-of-network, you will be reimbursed at the out-of-network provider coinsurance percentage after the deductible is met.

Ambulance Coverage
Benefits are available for ground and air ambulance. This coverage provides benefits of 80% of a maximum allowable charge of $350 for ground ambulance and $4,000 for air ambulance.

Prior Authorization
The purpose of prior authorization is to help ensure that patients receive services at the appropriate time and setting. A prior authorization confirmation is not a guarantee of benefits. Benefits are based on all terms and conditions of the coverage in force for the member at the time services are provided.

Prior authorization is required for all inpatient hospital stays. Failure to obtain prior authorization will result in benefits being reduced at 50%. (Network hospitals cannot bill the patient for services when they fail to obtain prior authorization.)

Prior authorization is also required for home health care, home infusion therapy, allergy testing, private duty nursing, skilled nursing facility, hospice care, prosthetic appliances, transplants, certain retail prescription drugs, specialty pharmacy products, inpatient and outpatient cardiac rehabilitation, 23-hour observation stays, inpatient rehabilitation facilities, physical therapy when performed at home and inpatient behavioral health care services.

Plan Exclusions
To keep your coverage affordable, there are some expenses and services which are not covered. The evidence of coverage provides complete details of benefits, exclusions, limitations and other plan provisions.

Pre-Existing Waiting Period – Benefits will not be provided for any pre-existing condition until a member has completed a waiting period of 12 months. A pre-existing condition is defined as an illness, injury, pregnancy, or any other medical condition which existed at any time preceding the effective date of coverage for which medical advice or treatment was recommended by, or received from, a provider of health care services or symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment.

Benefit Exclusion Rider – TRH underwriting guidelines may deem it necessary to attach a benefit exclusion rider to a member’s coverage. A benefit exclusion rider means a specific condition is excluded from coverage for the lifetime of the coverage.

Plan Exclusions

This information is an overview of the TRH Premier Children's coverage. Please consult the TRH Premier Child Evidence of Coverage (EOC) for complete details of benefits, exclusions, and general provisions. All applications must be medically underwritten and approved before coverage is issued.

Call your local TRH Representative today or Contact Us.