Summary of Benefits. Blue Cross Community Integrated Care Plan (ICP) SM. January 1, December 31, 2015

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1 Blue Cross Community Integrated Care Plan (ICP) SM Summary of Benefits January 1, December 31, 2015 Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association. ILICPSB15 Approved

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3 Summary of Benefits Thank you for your interest in Blue Cross Community ICP. Our plans are offered by Blue Cross and Blue Shield of Illinois. This Summary of Benefits tells you some features of our plan. It doesn t list every service that we cover or list every limitation or exclusion; and all services must be medically necessary. Where is Blue Cross Community ICP Available? The service area for Blue Cross Community ICP includes Cook, DuPage, Kane, Kankakee, Lake, and Will counties. Who is Eligible to Join Blue Cross Community ICP? You can join Blue Cross Community ICP if you are: Age 65 or older, or have a disability and over age 19 Receiving Medicaid but not eligible for Medicare Living in Cook, DuPage, Kane, Kankakee, Lake, Will counties. Do You Have Questions? Here are some numbers to call for more information: Blue Cross Community ICP Member Services If you have any questions about the plan, or if you need an interpreter or translation help with this document, please contact Member Services. Call toll-free TTY/TDD 711 We are open between 8 a.m. to 8 p.m. local time, seven days a week from October 1 to February 14. From February 15 to September 30 we are open 8 a.m. to 8 p.m. Central time, Monday through Friday. Alternate technologies (for example, voic ) will be used on the weekends and Federal holidays. The call is free. Llame al TTY/TDD 711. Estamos abiertos de 8 a.m. a 8 p.m., hora central, los siete días de la semana del 1 de octubre al 14 de febrero. Durante el 15 de febrero al 30 de septiembre, estamos abiertos 8 a.m. a 8 p.m., hora central, lunes a viernes. Se usará tecnologías alternas (por ejemplo, correo de voz) durante los fines de semana y feriados. La llamada es gratuita. Illinois Client Enrollment Services For questions about enrolling call: (TTY: ) Website: Other Languages: You can get this document in Spanish, or speak with someone about this information in other languages for free. Call TTY/TDD 711. The call is free. You can also call Member Services, toll free, to request this information in other alternative formats such as Braille, Large Print and other forms. Usted puede obtener este documento en español o hablar con alguien, de forma gratuita, acerca de esta información en otros idiomas. Llame al TTY/TDD 711. La llamada es gratuita. Usted también puede llamar al Servicio para Miembros, de forma gratuita, para solicitar esta información en otros formatos alternos tales como en Braille, en letra grande y de otras maneras. 1

4 Blue Cross Community Integrated Care Plan (ICP) Benefit Category Copay ICP Benefit Limit/Exclusions Provider Must Obtain Prior Authorization Abortion $0 Covered when mother s life Yes is endangered, result of rape or incest. Advanced Practice Nurse Services $0 No Ambulatory Surgical Treatment Center $0 Yes Service Audiology Services $0 No Chiropractic Services $0 Covered for enrollees under No age 21. Dental Services, including Oral Surgeons $0 No Emergency Dental Services $0 No Emergency Transportation/Ambulance $0 No Early Periodic Screening, Diagnosis and Treatment (EPSDT) Services $0 Covered for enrollees under age 21. Family Planning Services and Supplies $0 Including but not limited to: No Doctor visit Birth Control Family Planning and Education FQHCs, RHCs and other Encounter Rate Clinic Visits $0 No Hearing Aids and Batteries $0 One hearing aid/ear every three years. Batteries limited to 32 per 60 days. Home Health Agency Visits $0 For non-waiver services, coverage is limited to post-hospitalization care. No Hearing aids require prior authorization; batteries do not require prior authorization No Hospital Emergency Room Visits $0 No Hospital Inpatient Services $0 Yes Hospital Ambulatory Services $0 Yes Laboratory and X-ray Services $0 Yes, under certain circumstances. Genetic testing requires prior authorization. Hi tech radiology (MRI, CT, PET, etc.) requires prior authorization. Medical Supplies and Equipment $0 Yes, under certain circumstances. 2

5 Summary of Benefits Benefit Category Copay ICP Benefit Limit/Exclusions Provider Must Obtain Prior Authorization Mental Health (Behavioral Health) Services $0 Includes Inpatient, counseling, prescription drugs. Nursing Care $0 Covered for Enrollees under age twenty-one (21) not in the HCBS Waiver for individuals who are MFTD or for enrollees under 21 transitioning from a hospital to home placement or other setting. Nursing Facility Services $0 Yes Optical Services and Supplies $0 One pair of eye glasses every No two years. (*Also, see Added Benefits below) Optometrist Services $0 One eye exam per year. No Palliative and Hospice Services $0 Yes Pharmacy Services and Prescription Drugs $0 Quantity limits may apply. Yes Physical, Occupational and Speech Therapy Services Yes, under certain circumstances. $0 Evaluation and re-evaluation do not require prior authorization. All other physical, occupational, and speech therapy services require prior authorization. Physician Services $0 No Podiatric Services $0 No Post-Stabilization Services $0 No Practice Visits for Enrollees with $0 No Special Needs to the Dentist Prosthetics and Orthotics $0 No Radiology Services $0 No Renal Dialysis Services $0 Yes Respiratory Equipment and Supplies $0 Yes, under certain circumstances. Subacute Alcoholism and Substance Abuse Services, Day Treatment (Residential) and Day Treatment (Detox) $0 Yes, under certain circumstances. 3

6 Blue Cross Community Integrated Care Plan (ICP) Added Benefits The below are Added Benefits which are benefits you receive in addition to your standard benefits above. No copays $0 for doctor visits $0 for emergency room (ER) visits $0 for prescriptions Prescriptions 90-day supply mailed to your home Medicaid s four prescription limit per month does not apply Dental The following are additional dental benefits: Two oral exams each year Two preventative cleanings each year One set of x-rays per year Also, eligible pregnant women can get these additional dental services prior to the birth of their babies: Periodic oral examination Teeth cleaning Periodontal work Cell Phone You may qualify for a free cell phone to call your doctor, care coordinator, or 911 emergency services. Transportation In addition to the standard benefit of transportation to covered services, as an added benefit you may also get transportation to the pharmacy after a provider appointment. Optical (Vision) As part of your standard benefit, you receive one pair of eyeglasses every two years. As an added benefit, you can receive up to $100 towards a pair of upgraded eyeglass frames. Healthy Incentives Program You may qualify for gift cards for completing preventive services or going to your doctor after certain hospital or ER visits. *Some limits apply to the general dentistry above. For members with special needs, we cover practice visits to the dentist. 4

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