Making Changes (Changing Family Members) on Your. Contract This Schedule of Eligibility lets You know when You may add additional family Members to Your Contract. If Your coverage was purchased through an agent or through Blue Cross and Blue Shield of Louisiana, You will need to make all policy changes through the agent or through Blue Cross and Blue Shield of Louisiana. A Change of Status Card is the document that We must receive in order to enroll family Members not listed on Your original application/enrollment form. The Change of Status Card is used to add newborn children, newborn adopted children, or add or cancel a Spouse or other Dependents. It is extremely important that You follow the timing rules in the Schedule of Eligibility. If You do not complete and return a required Change of Status Card to Us within the timeframes set out in the Schedule of Eligibility, it is possible that Your insurance coverage will not be expanded to include the additional family Members or family members may not be removed from coverage. Completing and returning a Change of Status Card is especially important when Your first Dependent becomes eligible for coverage or when You no longer have any eligible Dependents. A Change of Status Card is also required to remove existing family Members listed on Your original application or enrollment form, or shown as covered in Our records. BENEFITS This Contract will have a Deductible that will apply to each Member. The Deductible per Member is the amount of expenses in covered Benefits each Member will have to pay out of his/her own pocket during the Benefit Period before any Benefits are payable under this Contract. This Contract has an Annual Maximum Benefit per Member. Once this Contract pays Benefits in that amount for a Member, no more Benefits will be covered for the rest of the Benefit Period for that Member. Each Benefit will have a Coinsurance amount assigned in the Schedule of Dental Benefits. The Coinsurance represents the percentage of the Allowable Charge that this Contract will pay for each covered Benefit. Any percentage not covered will be the responsibility of the Member. The applicable Deductible per Member, the Annual Maximum Benefit per Member, and Coinsurance for each Benefit will be disclosed in the Schedule of Dental Benefits. After the satisfaction of the Deductible, and subject to the Coinsurance and Annual Maximum Benefit Per Member, this Contract will cover the following Benefits:
