Premier Health Coverage

With TRH Premier, you can enjoy a $15 office visit copay, generous prescription drug coverage, benefits for well child care, and more. Claims for TRH Premier are administered by BlueCross BlueShield of Tennessee. This coverage utilizes the Blue NetworkP with more than 21,000 providers.

TRH Premier Coverage Brochure

• What's Covered
• Benefit Schedule
• Prescription Coverage
• Copayment Guidelines
• Well Child Care
• Maternity
• Provider Directory

What's Covered?

• Hospital services - inpatient and outpatient
• Physician services - inpatient and outpatient
• Prescription drug coverage (no annual dollar limit)
• Annual OB/GYN exams - one per year when performed by a network physician (copayment applies)
• PSA test
• Well child care and immunizations
• Maternity benefits (Benefits will be available only after family coverage has been in effect for nine consecutive months. There are no maternity benefits under individual coverage.)
• Emergency services
• Ambulance service - ground and air
• Diabetes treatment, equipment, supplies and education
• Durable medical equipment and supplies
• Home health care
• Skilled nursing and private duty nursing
• Behavioral health care services
• Physical therapy services
• Radiology and pathology services
• Organ transplants as specified in the Evidence of Coverage

Benefit Schedule
You can choose from three deductibles - $500, or $1,000 or $2,500.


$500 Deductible

Network Providers Out-of-Network Providers
Deductible	$500
Emergency Room Deductible (deductible each visit)	$75 $75
Office Visit Copayment	$15 N/A
Coinsurance	80% 60%
Out-of-Pocket Maximum - Individual - Family	$4,000 Unlimited $10,000 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

$1,000 Deductible

Network Providers Out-of-Network Providers
Deductible	$1,000
Emergency Room Deductible (deductible each visit)	$75 $75
Office Visit Copayment	$15 N/A
Coinsurance	80% 60%
Out-of-Pocket Maximum - Individual - Family	$5,000 Unlimited $12,500 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

$2,500 Deductible

Network Providers Out-of-Network Providers
Deductible	$2,500
Emergency Room Deductible (deductible each visit)	$75 $75
Office Visit Copayment	$15 N/A
Coinsurance	80% 60%
Out-of-Pocket Maximum - Individual - Family	$12,500 Unlimited $31,250 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 precent 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 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: All maternity services, all therapeutic services, allergy testing and injections, behavioral health care services, biopsy interpretations, bone density testing, cardiac diagnostic testing, chemotherapy services, chiropractic services, CT scans, CTA scans, dental services, diagnostic services sent out, DME and DME supplies, growth hormone injections, IV therapy, Lupron injections, mammography, MRI, MRA, MRS, nerve conduction studies, neuropsychological or neurological tests, nuclear cardiology, nuclear medicine, orthotics, PET scans, prosthetics, provider administered specialty pharmacy products, sleep studies, surgery performed in a physician's office and related surgical supplies, Synagis injections, and ultrasounds. These services 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:

• Physical Examinations
  • Under age 1: four exams from birth to the child’s first birthday
  • Age 1: two exams from the child's first birthday to the child’s second birthday
  • Age 2 - 6: one exam per year (The child’s birthday determines when a year begins and ends.)
• 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.

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

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

Prior Authorization
The purpose of prior authorization is solely to ensure that 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 to 50 percent. (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, certain high-tech imaging, physical therapy when performed at home and inpatient behavioral health care services.

Exclusions
To keep your coverage affordable, there are some expenses and services which are not covered. The EOC 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 – Benefits are available after TRH family coverage has been in effect for nine consecutive months. There are no maternity benefits on individual 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

This information is an overview of the TRH Premier coverage. Please consult the TRH Premier 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.