Surgery Services. This plan covers surgery services to treat a disease or injury when: • the operation is not experimental or investigational, or cosmetic in nature; • the operation is being performed at the appropriate place of service; and • the physician is licensed to perform the surgery. Preauthorization may be required for certain surgical services. Reconstructive Surgery for a Functional Deformity or Impairment This plan covers reconstructive surgery and procedures when the services are performed to relieve pain, or to correct or improve bodily function that is impaired as a result of: • a birth defect; • an accidental injury; • a disease; or • a previous covered surgical procedure. Functional indications for surgical correction do not include psychological, psychiatric or emotional reasons. This plan covers the procedures listed below to treat functional impairments. • abdominal wall surgery including panniculectomy (other than an abdominoplasty); • blepharoplasty and ptosis repair; • gastric bypass or gastric banding; • nasal reconstruction and septorhinoplasty; • orthognathic surgery including mandibular and maxillary osteotomy; • reduction mammoplasty; • removal of breast implants; • removal or treatment of proliferative vascular lesions and hemangiomas; • treatment of varicose veins; or • gynecomastia. Preauthorization may be required for these services.
Surgery Services. For diagnostic imaging, lab, and machine tests see Section 3.37.
Surgery Services. If you are admitted to a general hospital as an inpatient for a medical condition, we cover the services of a doctor in charge of your medical care, up to one (1) visit per day. If you are admitted for surgical, obstetrical, or radiation services, our allowance to the doctors who performed your surgery, delivered your child, or supervised your radiation includes payment for all your related hospital visits by these doctors during your admission. If, while you are in the hospital, the attending doctor in charge of your care asks for the assistance of a doctor who has special skills and knowledge to diagnose your condition, we cover a consultation performed by a specialist. The transferring of a patient from one doctor to another is not considered to be a consultation. A specialized doctor who then treats you as his or her patient is not considered to be a consultant If you need inpatient specialty care for a condition that requires skills the doctor in charge of your care does not have, we will cover specialist visits as medically necessary.
Surgery Services. For a specialist exam, see Section 3.24 - Office Visits. For diagnostic imaging, lab and machine tests see Section 3.37. See the Summary of Medical Benefits for benefit limits and the amount that you pay for each type of service. If you are admitted to a non-network hospital from the emergency room, BCBSRI recommends you obtain preauthorization to receive inpatient services. Call our Customer Service Department at (000) 000-0000 or 0-000-000-0000 with any questions you have about your coverage. Follow-up care (such as suture removal, fracture care or wound care) should be obtained from your primary care physician or a specialist.
Surgery Services. This plan covers surgery services to treat a disease or injury when: the operation is not experimental or investigational, or cosmetic in nature; the operation is being performed at the appropriate place of service; and the physician is licensed to perform the surgery.
Surgery Services. For a specialist exam, see Section 3.23 - Office Visits. For diagnostic imaging, lab and machine tests see Section 3.35. See the Summary of Medical Benefits for benefit limits and the amount that you pay for each type of service. If you are admitted to a non-network hospital from the emergency room to receive inpatient services call our Customer Service Department at (000) 000-0000 or 0-000-000-0000 with any questions you have about your coverage. Suture removal, performed where the original emergency services were received, is covered as part of our allowance for the original emergency treatment. We will ONLY cover a separate charge for suture removal if the suturing and suture removal are performed at different locations (i.e. sutures at emergency room and suture removal at doctor’s office).
Surgery Services. Inpatient doctor services 20% - After Deductible 40% - After Deductible Outpatient doctor services 20% - After Deductible 40% - After Deductible In a doctor’s office 0% 40% - After Deductible Telemedicine Telemedicine services When rendered by a designated provider. $25 Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 20% - After Deductible 40% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 40% - After Deductible Lab and pathology services. 0% 40% - After Deductible Diagnostic colorectal services (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 20% - After Deductible 40% - After Deductible Lyme disease-diagnosis 20% - After Deductible 40% - After Deductible Urgent Care Center Urgent care center/walk-in $50 $50 Vision Care Services Vision exam One routine eye exam per member per plan year. $40 40% - After Deductible BENEFIT BOOKLET Blue Cross & Blue Shield of Rhode Island TABLE OF CONTENTS SUMMARY OF MEDICAL BENEFITS 3 FLEX PLAN 4 1.0 INTRODUCTION 14
Surgery Services. Inpatient - doctor services 0% - After Deductible 0% - After Deductible 50% - After Deductible Outpatient - hospital, ambulatory or independent surgical center - doctor services 0% - After Deductible 0% - After Deductible 50% - After Deductible In a doctor’s office - doctor services 0% 0% 50% - After Deductible Telemedicine Telemedicine services - When rendered by a designated provider. $5 $5 Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient Hospital facility, free standing facilities owned and/ or affiliated with a hospital, or certain designated free standing facilities MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear cardiac imaging* Copayment is applied per service. $600 $600 50% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $150 $150 50% - After Deductible Lab and pathology services. Copayment is per provider per day. $75 $75 50% - After Deductible Outpatient Hospital facility Sleep Studies $600 $600 50% - After Deductible Outpatient Non-Hospital facility including in a doctor’s office, urgent care center, or free-standing outpatient facility, or other non-hospital setting Sleep Studies $200 $600 50% - After Deductible Outpatient Non-Hospital facilities: including; in a doctor’s office, urgent care center, or certain designated free- standing outpatient facilities MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear cardiac imaging* Copayment is applied per service. $200 $600 50% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $50 $150 50% - After Deductible Lab and pathology services. Copayment is per provider per day. $25 $75 50% - After Deductible Diagnostic colorectal services (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After Deductible 0% - After Deductible 50% - After Deductible Lyme disease-diagnosis 0% - After Deductible 0% - After Deductible 50% - After Deductible
Surgery Services. Inpatient physician services 0% - After deductible 20% - After deductible Outpatient physician services 0% - After deductible 20% - After deductible In a physician’s office 0% 20% - After deductible Telemedicine Services When rendered by a designated provider. $25 Not Covered When rendered by a network provider. $25 Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear medicine*. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than the diagnostic imaging services listed above. $75 20% - After deductible Lab and pathology services. $25 20% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment $25 20% - After deductible Urgent Care Urgent care services $100 The level of coverage is the same as network provider. Vision Care Services Vision exam - one routine eye exam per member per plan year. $0 20% - After deductible Non-routine eye exam $0 20% - After deductible Pediatric vision care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19:. Prescription glasses - frame and lenses 0% Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty, pharmacy.
Surgery Services. If you are admitted to a general hospital as an inpatient for a medical condition, we cover the services of a doctor in charge of your medical care, up to one (1) visit per day, for the same number of days allowed under Section 3.17 -
