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Presenting
The Blue Solution PPO
Insurance Policy.
The benefits you need…
from the name you know and trust…
at a price you can afford.
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Blue Solution PPO Insurance Policy Benefits At-A-Glance
Benefits
In-Network
Lifetime Benefit Maximum
Deductibles
Choice of four deductibles.
Maximum of two deductibles per family, per
calendar-year. Expenses incurred toward the
deductible during the last three months of the
calendar year may also be used to satisfy the
deductible for the succeeding calendar year.
Out-Of-Network
$2 Million
$ 750
$ 1,500
$ 3,000
$ 5,000
$ 1,500
$ 3,000
$ 6,000
$10,000
80%
100%
60%
80%
$10,000
Not applicable.
$20,000
No maximum.
$30 copayment at in-network general
practitioners, pediatricians, family
practitioners, and internal medicine
doctors with NO deductible for these
routine office visits. (General Coverage
Limitations apply. See back of brochure.)
$30 copayment at in-network general
practitioners, pediatricians, family
practitioners, and internal medicine
doctors with NO deductible for these
routine office visits. (General Coverage
Limitations apply. See back of brochure.)
60% after deductible is satisfied.
For out-of-network benefits,
see “Benefits Summary.”
Coinsurance — What Your Plan Pays
$750, $1,500, $3,000
$5,000
Calendar-Year Coinsurance Maximum
$750, $1,500, $3,000
$5,000
Maximum of two calendar-year coinsurance
maximums per family, per calendar-year.
General Doctor Visits
$750, $1,500, $3,000
$5,000
80% after deductible is satisfied.
For out-of-network benefits,
see “Benefits Summary.”
Specialist Visits
$750, $1,500, $3,000
$5,000
80% after deductible is satisfied.
100% after deductible is satisfied.
60% after deductible is satisfied.
For out-of-network benefits,
see “Benefits Summary.”
80% after deductible is satisfied.
For out-of-network benefits,
see “Benefits Summary.”
Prescription Drugs
Must use participating pharmacies.
Covered 50% after a separate $250
deductible per person is satisfied.
There is no coverage if you use
out-of-network pharmacies.
$500 annual maximum (per person)
with no deductible or copayment.
Applicable coinsurance does apply.
$500 annual maximum (per person)
with no deductible or copayment.
Applicable coinsurance does apply.
100%
100%
100%
100%
80% after deductible is satisfied.
100% after deductible is satisfied.
60% after deductible is satisfied.
80% after deductible is satisfied.
Wellness Benefits
Routine Exams
• Routine physical exams
• Routine gynecological exams
• Routine mammograms
Children’s Preventive Care
Well-patient services (office visits only).
Immunizations
Maternity Rider — Optional
$750, $1,500, $3,000
$5,000
IMPORTANT NOTE: Your premium will be accepted after coverage has been approved and a billing statement forwarded. This outline of coverage provides a brief
description of the important features of your Blue Solution PPO insurance policy. The outline is not your policy, and only the actual policy provisions will control. The
policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY.
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Blue Solution PPO Benefits Summary
This health insurance policy offers these attractive benefits and services
Basic Provisions:
• Provides comprehensive major medical protection
• Available to individuals and families, ages 0 – 64, not
eligible for Medicare
Note: Family coverage is not available for applicants under
the age of 18. Family coverage includes “Individual/Spouse,”
“Individual/Child(ren)” and “Individual/Spouse/Child(ren).”
If you are including child(ren) with either parent or elect full
family coverage, one premium amount covers all your
dependent children from birth to age 23 (if a full-time college
student), no matter how many children are insured. Upon
reaching the age of ineligibility (19 or 23, depending on
academic status), dependent children may receive guaranteed
conversion to their own individual policy with the same
benefits (certain rules apply).
• Choice of deductible (see the benefit comparison chart)
• $2,000,000 lifetime maximum
• Calendar year deductible
• Deductible carryover
• Calendar year benefit period (Jan. 1 – Dec. 31)
• Coordination of benefits
• Dependents covered until age 19 or age 23 if child is
full-time student; no age limit for disabled children
(certain rules apply)
• Age and sex rated (premium based on the age and sex
of the oldest person)
Hospital Benefits:
• Operation and recovery rooms
(includes outpatient surgery)
• Semi-private room and board
• Intensive care
• Required diagnostic X-ray and lab tests
• Complications of pregnancy
• Anesthesia services
• Drugs and supplies
• Newborn services (unless individual policy)
• Voluntary sterilization (reversal not covered)
Outpatient Benefits:
• Physician outpatient care
• Surgery
• Radiological therapy
• Injectible chemotherapy
• Medical emergencies
• Outpatient X-ray and lab tests
• Private duty nursing*
• Drugs and supplies
Physician Benefits:
• Office visits
• In-hospital visits
• Surgery
• Anesthesia
• Outpatient X-ray and lab tests
• Complications of pregnancy
• Durable medical equipment
• Inpatient psychiatric treatment*
Maternity Option (prenatal/obstetrics):
This optional benefit is available only to individuals 18 years
of age and older. Maternity coverage includes:
• Obstetric care
– Physician services
– Labor and delivery room
Note: Newborns are automatically added to family policies
if the appropriate forms are filed within 90 days of birth.
Individual policies, however, cover the mother only. If you
choose “Individual” coverage, any dependents you choose
to add in the future — including newborns — will be
medically underwritten, and the effective date of the coverage
will be subsequent to the approval date. This means — with
an “Individual” policy — there is no possibility of a newborn
being covered from date of birth. Newborns will be considered
for coverage only after our review of the medical records from
their two-month check-up. In-network, the rider is subject
to your deductible and coinsurance. (For out-of-network
benefits, see “Out-of-Network Benefits” below.) The
maternity rider can only be added at the time of application
and must be effective prior to conception. A policyholder
who subsequently marries may apply to add maternity
coverage. Application for the maternity rider must be made
within 30 days of the date of marriage and effective prior
to conception.
Out-of-Network Benefits:
For out-of-network providers, you must satisfy double your
in-network deductible before the insurance plan begins to
pay benefits. (For instance with individual coverage, if your
in-network deductible is $1,000, your out-of-network
deductible will be $2,000.) Once you’ve satisfied your
out-of-network deductible, any applicable coinsurance
and calendar-year coinsurance maximum amounts are also
doubled for out-of-network providers. In addition, if you
go out-of-network, you will also be responsible for any
“balance billing” — in other words, the difference between
the provider’s bill and the Arkansas Blue Cross and
Blue Shield allowed amount.
Deductible Carryover:
Expenses incurred toward the deductible during the last three
months of the calendar year may also be used to satisfy the
deductible for the succeeding calendar year.
Term Life Insurance:
Term life insurance is an optional benefit offered by USAble
Life, an affiliate of Arkansas Blue Cross and Blue Shield,
to proposed insureds and their covered spouses ages 18 – 64.
See the enclosed USAble Life brochure for more information.
* Refer to “General Coverage Limitations” in this brochure.
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IMPORTANT INFORMATION
Tobacco Users: The rates provided are discounted non-tobacco-user premiums. An additional 20% will be applied
to any tobacco-user’s amount of premium.
Benefits and Services Not Included: Maternity coverage (if elected) is not covered if conception occurred prior
to the effective date of the policy. No benefits or services of any kind are provided for maternity care, obstetrical care,
in vitro fertilization, artificial insemination, and other infertility-related procedures unless maternity coverage is elected.
Conditions existing prior to the effective date of the policy are not covered until the policy has been in effect for
12 months.
Injuries or diseases caused by war; dentistry, (except for some oral surgery); eye refractions, eyeglasses or hearing
aids, unless needed because of accidental injury; cosmetic surgeries, unless needed because of accidental injury;
services or supplies not medically necessary; medical or hospital services collectible under Workers Compensation
or any law providing benefits for dependents of military personnel; services rendered in government hospitals;
intentionally self-inflicted injuries; inpatient services, if they could have been performed safely and adequately on an
outpatient basis; services and supplies which are experimental or investigational in nature; benefits provided under
Medicare or other government programs (except Medicaid); services of social workers, unless included as part of
the daily room and board allowance; radial keratotomies or epikeratophakia or any services performed to correct
nearsightedness; hospital and physician services for rest cures; services by an immediate relative (spouse, parents,
children, brother, sister, or legal guardian); dietary supplements when used in connection with weight reduction
programs. Renewal may be refused by class.
Limitations of Hospital Benefits: Arkansas Blue Cross and Blue Shield does not require pre-admission
certification for in-state hospital admissions. Notification only is required for out-of-state or out-of-network
hospital admissions at the time of admission by calling the toll-FREE number on the back of your ID card.
Services rendered in a hospital outside of the United States of America will be paid at the sole discretion of the Plan.
General Coverage Limitations: Home health care is limited to 40 visits per calendar year; outpatient physical
therapy, occupational therapy, respiratory therapy, and speech therapy is limited to 45 visits per calendar year;
ambulance coverage is limited to $500 per year; durable medical equipment is limited to $5,000 per calendar year;
treatment for the following conditions is limited to 50% payment to $4,000 per calendar year combined: alcoholism,
drug addiction, and psychiatric conditions. Alcoholism and drug addiction are limited to two (2) admissions per
covered person per lifetime. Prior written approval must be received for gastric bypass surgery or any procedure
performed for the purpose of weight loss; nursing home — maximum 30 days per calendar year. All organ
transplants, except kidney and cornea transplants, are subject to prior approval. The maximum lifetime benefits
shall not exceed $2,000,000 per covered person.
Subrogation: If benefit payments are made for which a third party may be liable, Arkansas Blue Cross and Blue
Shield is entitled to recovery out of payments made by that third party to the full extent of benefits paid.
Medical Underwriting: This health insurance is underwritten. To be approved for coverage and issued a policy,
you must answer health questions and pass medical underwriting.
Coordination Against Group and Major Medical Coverage: Benefits for services or supplies available to you
under any other group or blanket disability insurance, Union Welfare Plan, employer or employee benefit organization,
self-insurance or any other non-regulated group disability benefits plan, major medical policy, or no-fault automobile
liability insurance will be coordinated so that the total amount of benefits payable from all these plans combined does
not exceed 100% of actual medical expenses.
Since applications for our Blue Solution PPO insurance policy take time to process and
you are not guaranteed coverage, we advise you to keep your current coverage in effect
until we notify you that your new coverage is active. If you do not have health insurance
coverage at this time, you may want to consider applying for our Short-Term Blue insurance
policy. Assuming you meet the minimum qualifications, you could have Short-Term Blue
coverage in place while we are medically underwriting your application for Blue Solution
PPO.
ARKS00391-BH(09/04)-DIR