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Service
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CompCare Benefit
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Professional Services
Inpatient & Outpatient
Physician Office Visits
Limited
to:
Sick Care
Routine/Preventive Care:
Well-Child Care
·
In-hospital physician
·
Office visits – seven
visits age birth-1
·
Immunizations to age 8
·
Blood lead screening
Well-Adult Care
·
Mammography screening – age
40+ one every year
·
Gynecological exam one
every 12 months
·
Cholesterol screening one every
three years
·
Tetanus booster as
necessary
Family
Planning:
Maternity Care:
Pre
& postnatal
Delivery
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80%
$20
co-payment (No deductible)
100% No
Deductible (scheduled benefits)
Not covered
(except sterilization’s, which are covered
at 80%)
80%
80%
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Diagnostic Services
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80%
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Infertility Treatment
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Not covered
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Ambulance
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80%
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Occupational Therapy, Physical Therapy,
Speech Therapy
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80%
$3,000 combined limit per
member per calendar year
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Chiropractic Care - Physical
Manipulations/Adjustments
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80%
Up to 30 visits per member
per calendar year
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Smoking
Cessation
Approved Smoking
Cessation Program
Physician follow-up
visits (up to 2 visits)
Nicotine
replacement therapy medications prescribed by a physician (i.e. gum, patch,
nasal spray, Zyban)
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$35
maximum allowance per program, $70 per lifetime
$20 co-payment (No deductible)
Drug co-pay of $10
generic; $20 brand name;
$30 optional brand name
(Maximum benefit $200 per member per calendar year;
$400 per member per lifetime.
This maximum only applied to smoking cessation drugs)
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Skilled Nursing Facility
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80%
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Home Health Care
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80%
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Hospice
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80%
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Durable Medical Equipment
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80%
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Temporomandibular Joint
(TMJ) Syndrome Services
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Not Covered
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Prescription
Drug Coverage
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Member
Co-pay for up to a 30-day supply:
$10
Generic/ $20 Brand name/ $30 Optional Brand name
(Deductible
does not apply)
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Mental Health Care
Inpatient
Listed Illnesses*
Non-listed Illnesses
Outpatient
Listed Illnesses*
Non-listed Illnesses
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80%
80% (After $150
Mental Health deductible)
Up to 31 days per member per calendar year
2 days of
day treatment equal 1 day of inpatient services
80%
50% (After $150
Mental Health deductible)
Up
to 40 visits per member per calendar year
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Important Information On Receiving Mental Health & Substance Abuse Benefits
*Listed Mental Illnesses: Maine law requires
benefits be provided at the same benefit level provided for medical treatment
for the following listed mental illnesses: schizophrenia, bipolar
disorder, pervasive developmental disorder (autism), paranoia, panic
disorder, obsessive-compulsive disorder, and major depressive disorder.
Non-listed mental
health coinsurance amounts do not go toward meeting your annual coinsurance
limit.
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Substance
Abuse
Inpatient
Outpatient
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90% (After $150 Substance Abuse deductible)
Up to 31 days per member
per calendar year – 62 days per lifetime.
2 days of day treatment equal 1
day of inpatient services
80% (After $150 Substance Abuse deductible)
Up to $1,500 per
member per calendar year
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Coinsurance amounts do not go toward meeting
your annual coinsurance limit.
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Notes: The
following health promotion programs, materials, and discounts are available
to CompCare members: Our prenatal care program and
health and fitness discounts at select fitness clubs and health
organizations.
When services are received from a non-participating Anthem Blue
Shield physician, benefits will be reduced by 20%. The member may be responsible for filing
claims and paying balance bills in addition to the deductible and
coinsurance.
Benefits
are based on our maximum allowance for covered services. Maximum allowance is the maximum amount we
will pay for a particular service.
Anthem Blue Cross and Blue Shield network health care providers and
professionals have agreed to accept our maximum allowance as payment in full
and cannot balance bill for excess charges.
The following are examples of services NOT covered by CompCare:
temporomandibular joint syndrome (TMJ), cosmetic surgery & vision
therapy.
Please Note: This Benefit Overview covers only the highlights of
this type of health plan.
If there are questions regarding benefits, call a customer
service representative at 1-800-482-0966 or 822-7272.
THIS IS NOT A CONTRACT
It is an overview of your
benefits. For
more detailed information, please contact your benefits administrator or ask
us for a copy of the Certificate of Coverage for this health plan. If there
are discrepancies between this benefit overview and the Certificate of
Coverage, the Certificate will govern.
R04/03
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