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Covered Services

The following covered services and supplies are eligible expenses when they are medically necessary and appropriate, and prescribed and performed by an eligible provider for the diagnosis or treatment of an illness or accidental injury.

Hospital Inpatient Services – room, board and general nursing care; use of operating and treatment rooms; diagnostic services.

Hospital Outpatient Services – treatment of a sudden and serious illness or accidental injury; pre-admission testing; ambulatory surgery; diagnostic services.

Emergency Services – services furnished by a hospital which are required to determine, evaluate, and/or treat an emergency medical condition.

Ambulance Services – benefits are available for ground and air ambulance. This coverage provides benefits of 80 percent of a maximum allowable charge of $450 for ground ambulance and $5,000 for air ambulance.

Physician Services – office visits; outpatient and inpatient surgery.

Diagnostic Services – laboratory and pathology services; x-ray and other radiology services.

Home Health Care – part-time or intermittent nursing care, physical or respiratory therapy, home infusion therapy, oxygen and its administration. Benefits are limited to 45 visits per calendar year.

Prescription Drugs – drugs prescribed by a licensed physician, approved by the FDA, dispensed by a licensed pharmacist, and unavailable for purchase without a prescription.

Behavioral Health Care – treatment for mental or nervous conditions; substance abuse treatment. Benefits are provided at 50 percent with an annual maximum of $7,500 and a lifetime maximum of $30,000.

Durable Medical Equipment – medically necessary durable medical equipment and supplies.

Organ Transplants – medically necessary and appropriate services for heart, heart/lung, bone marrow, lung, liver, pancreas, pancreas/kidney, kidney, small bowel, and small bowel/liver. There is a separate network of providers for transplant services. Prior authorization is required for services to be covered.

Benefit Schedule

Major Medical 5000 Health Coverage

*Deductible is per calendar year.

Cost-Saving Features

Network Providers – The TRH Major Medical 5000 utilizes the Blue Network P. This network is comprised of hospitals, physicians, home health care agencies, ambulatory surgical facilities, pharmacies and other eligible providers. These providers have agreed to special pricing arrangements. Members receive the highest level of benefits when using a network provider.

If a member chooses an out-of-network provider, benefits may be substantially reduced and out-of-pocket expenses may be higher.

Prior Authorization – The purpose of prior authorization is solely to ensure patients receive services at the appropriate time and in the appropriate 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. (Network hospitals cannot bill patients 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, certain high-tech imaging, physical therapy when performed at home and inpatient behavioral health care services.

Care Management – Care management provides cost-effective treatment alternatives for patients with complicated, chronic, and/or catastrophic illnesses or injuries. Care management involves a systematic process of assessing, planning, service coordination and monitoring through which multiple needs of patients are met.

Concurrent Utilization Review – The goal of concurrent utilization review is to encourage the appropriate use of hospitalization.

Network Providers

The Blue Network P offers members a network of hospitals, physicians, ambulatory surgical facilities, home health agencies, pharmacies and other providers. Network providers have agreed to special pricing arrangements. When using network providers, members are responsible for applicable deductibles and coinsurance for covered services.

When using an out-of-network provider, a member’s benefits may be substantially reduced and out-of-pocket expenses may be higher. There are no limits to a member’s out-of-pocket expenses when using out-of-network providers.

Blue Network P Provider Directory

Eligible transplant services use a separate Transplant Network of providers. To receive the highest level of benefits for eligible transplant services, members must use the Transplant Network. Transplant services require prior authorization. For a list of Transplant Network providers contact the Administrator, BlueCross BlueShield of Tennessee.

Plan Exclusions

To keep the TRH Major Medical 5000 coverage affordable, there are some services that 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.

Maternity Benefits – There are no maternity benefits with this coverage.

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 a specified length of time.

Plan Exclusions

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