www.bcbsla.com
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01MK1418 R2/13
Plans effective 1/1/20
affordable group
health Insurance ...
only from the
Cross and Shield!
What’s Inside
Introducing trueBLUE
The trueBLUE Difference
trueBLUE Benefits
Solid PPO Provider Network
Deductibles and Coinsurance
Out-of-Pocket Maximums
Preventive Care
Prescription Drug Program
Special Options and Features Owner 24-Hour Coverage
Accidental Injuries
Organ, Tissue and Bone Marrow Transplant Benefits Mental and Nervous/Alcohol and Drug Abuse
Pregnancy Care Care Management Programs Customer Service
Value-Added Services
Cafeteria Plans General Conditions Benefit Summary Chart
Small Employer Notice
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NOTICE: Healthcare services may be provided to you at a
network healthcare facility by facility-based physicians who
are not in your health plan. You may be responsible for payment
of all or part of the fees for those out-of-network services,
in addition to applicable amounts due for copayments,
coinsurance, deductibles and non-covered services.
This proposal is presented for general information only.
It is not a Benefit Plan, nor intended to be construed as
a Benefit Plan. If there is any discrepancy between this
document and the Benefit Plan, the Benefit Plan will
govern the benefits paid.
For complete information, please refer to the Benefit Plan.
Premium will vary with the amount of benefits chosen.
trueBLUE refers to Benefit Plan #40HR1543.
Specific information about in-network and out-of-network
facility-based physicians can be found at www.bcbsla.com or
by calling the customer service telephone number on the back
of your ID card.
Cafeteria Plans refer to Flexible Spending/Cafeteria
Section 125 contract #28XX1412.
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Affordable group health insurance?
You better believe it!
If you thought group health coverage was out of your reach, you’ll be glad to know
there’s an innovative plan that gives your employees the protection they deserve
at a price you can afford!
As an employer, you benefit in a number of ways by providing health insurance to
your employees. The most obvious benefit is employee retention. A study conducted
by Randstad North America showed that 70 percent of employees ranked healthcare
coverage as the most important benefit offered by a company. Insured employees
also tend to seek the care of a doctor more often than uninsured employees, making
them healthier and keeping production levels up. Additionally, tax benefits ensure
that healthcare is a very cost-effective way to compensate employees – employer
contributions are 100 percent tax deductible.
trueBLUE is a fully comprehensive health plan that offers substantial
savings over other plans.
trueBLUE covers a complete list of comprehensive services, including:
• Doctor visits
• Visits to other healthcare providers
•Lab tests
• X-rays
• Prescription drugs
• Inpatient procedures
•Outpatient procedures
Information on the most current rating is
available at www.standardandpoors.com or by calling
Standard & Poor’s at 212.438.2400.
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®
trueBLUE
Introducing trueBLUE from Blue Cross and
Blue Shield of Louisiana
®
This innovative
coverage features
comprehensive networks
that are both affordable
and predictable.
THE trueBLUE Difference
trueBLUE offers options to fit your needs and budget.
trueBLUE’s unique benefit design is divided into
two benefit categories: (1) Inpatient/Outpatient
services and (2) Prescription Drugs. Services and
supplies rendered in an inpatient setting and services
performed on an outpatient basis are included in the
Inpatient/Outpatient benefit category (see example
below). Brand-name and generic prescription drugs are
included in the Prescription Drugs benefit category.
®
(1)
(2)
Inpatient/OutpatientPrescription Drugs
physician & allied provider charges
X-rays
lab tests
hospital and allied
facility charges
emergency room services
brand-name & generic
prescription drugs
prescription drugs administered
in an inpatient setting
®
The trueBLUE
Difference
trueBLUE: The Affordable Alternative
We found a way to make trueBLUE so affordable
through a simple cost-sharing idea. Like other
comprehensive plans, trueBLUE requires that
a deductible first be met before benefits are paid.
A deductible is an amount that the member must pay
out-of-pocket in a benefit period (calendar year)
before coverage begins. In such cases, the member
pays the first dollars of his or her coverage. Once the
deductible is met, the costs of healthcare are shared
between Blue Cross and the member on a percentage
basis. This shared percentage is called the coinsurance.
Unlike other plans, a separate deductible applies to
each of the two benefit categories above.
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• Solid PPO Provider Network
• Lifetime Maximum
• Deductibles & Coinsurance
• Out-of-Pocket Maximums
• Preventive Care
• Prescription Drug Program
®
Solid PPO Provider Network
Our roots in the Louisiana medical community
date back to 1934, when the forerunner of today’s
company was founded. Because of our longstanding
relationship with hospitals, physicians and
other providers in the state, we are able to offer
special features to our members and pass on the
cost savings.
The PPO network is a select group of hospitals,
physicians and allied providers who have contracted
with us and agreed to accept the lesser of billed
charges or a negotiated amount as payment in full
for covered services. This amount is called the PPO
provider’s allowable charge and is used to determine
our payment for covered services. The PPO benefit
option provides the highest level of coinsurance
when members receive care from PPO network
providers. When covered services are received
from a non-participating hospital or provider,
benefits will be reduced. See Benefit Plan for
details. Provider information can be found on our
website at www.bcbsla.com.
®
trueBLUE
Benefits
Deductibles and Coinsurance
trueBLUE PPO plans offer a variety of deductibles:
®
®
• $500
• $750
You choose one deductible amount for each of the
two benefit categories. This deductible must be met
for each benefit category before coinsurance begins
for that category. Once the deductible is met for
the Inpatient/Outpatient benefit category, trueBLUE
pays 80 percent of the allowable charge for covered
services received by a PPO provider and 60 percent
of the allowable charge for covered services
received by a non-PPO provider in the applicable
benefit category.
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trueBLUE
Benefits
• $1,000
Once the deductible is met in the Prescription Drugs
benefit category, trueBLUE plans pay 50 percent for
brand-name prescription drugs and 100 percent for
generic prescription drugs. For example:
(1)
(2)
Out-of-Pocket Maximums
trueBLUE also allows you to choose one out-of-pocket
maximum for each benefit category: $1,000 or $2,000.
Once this maximum is reached, trueBLUE pays 100
percent of the allowable charge for covered expenses.
For example:
Inpatient/OutpatientPrescription Drugs
$500 deductible
$500 deductible
(2)
Inpatient/OutpatientPrescription Drugs
once met, trueBLUE PPO pays
80% in-network
50% brand-name prescription drugs
60% out-of-network
100% generic prescription drugs
(1)
once met, trueBLUE
PPO pays The deductible applies to a January 1 through
December 31 calendar-year benefit period. Each
covered family member has an individual deductible;
once three family members reach their deductibles,
no other member has to satisfy a deductible within
the same category for that benefit period. The family
deductible applies separately to the Inpatient/
Outpatient and Prescription Drugs benefit categories.
$1,000 out-of-
pocket max
$1,000 out-ofpocket max
once reached, trueBLUE
once reached, trueBLUE pays 100% of allowable
pays 100% for brandcharges for covered services name prescription drugs
100% for generic prescription drugs
For extra protection, there is a combined out-ofpocket maximum for family coverage for the Inpatient/
Outpatient benefit category. If the member’s individual
out-of-pocket maximum is $1,000, the family outof-pocket maximum is two-and-a-half times that
amount. If the member’s individual out-of-pocket
maximum is $2,000 or more, the family out-of-pocket
maximum is twice that amount.
• $1,000 X 2 ½ = $2,500
• $2,000 X 2 = $4,000
There is no family out-of-pocket maximum for
prescription drugs.
Preventive Care
Blue Cross and Blue Shield of Louisiana is committed
to preventive care. Detecting illnesses in their early
stages ensures better health for our members and
reduces medical costs for everyone. To promote
preventive care, trueBLUE covers a full array of wellness
services. Blue Cross pays 100 percent of the allowable
charge, with no deductible needed, on the following
services when rendered by a preferred provider:
• routine physical exam
• digital rectal exam and prostate specific antigen
(PSA) screening test (age 50 and older), if
recommended by physician
• routine hemoccult (colon) test
• routine gynecological (pelvic) exam
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network pharmacist and he or she will determine the
discounted charge. The pharmacist will automatically
file a claim on behalf of the member and advise the
member when the deductible has been satisfied.
Prescriptions filled at a retail pharmacy may be limited
to a 30-day supply.
Mail-Order Service
For prescriptions used on an ongoing basis – such as
medication for blood pressure, asthma or diabetes –
mail service may be more cost-effective for the
member. To use this service, members simply mail or
fax their prescriptions to our mail-order pharmacy,
Express Scripts, Inc., for up to a 90-day supply.
Members have ongoing access to prescription drug
information through the Express Scripts website at
www.express-scripts.com.
• well baby care
• immunizations as recommended by the member’s
physician
• routine Pap smear
• mammogram screening as recommended by the
member’s physician
• autism screening
• breast cancer screening
• cervical cancer screening
• depression (adults) screening
• HIV screening
• lipid disorders (adults) screening
• phenylketonuria (PKU) screening
• type 2 diabetes mellitus (adults) screening
• visual impairment in children younger than age 5
years screening
Wellness services received from non-PPO providers are
subject to out-of-network coinsurance levels.
Step Therapy
In some cases, you may be required to try a certain
prescription drug to treat a condition in order to
receive coverage. If this drug does not work for
your condition, we will cover a second prescribed
medication.
Quantity Per Dispensing Limitations & Allowances
Covered prescriptions have a quantity limit described
in your benefit plan (typically up to a 30-day supply
at a retail pharmacy and up to a 90-day supply
for mail-order). These limits are based on the
manufacturer’s recommended dosage and duration
of therapy; common usage for episodic or intermittent
treatment; FDA-approved recommendations
and/or clinical studies; and/or as determined by
Blue Cross and Blue Shield of Louisiana.
QPD limits/allowances are subject to quantity
limits per day supply, per dispensing event, or any
combination thereof.
Prescription Drug Program
Since prescription drugs can be a costly part of your
healthcare, trueBLUE includes a prescription drug
benefit that helps to defray these costs. Members may
access prescription drugs through retail pharmacies or
through our mail-order service.
Broad Pharmacy Retail Network
Blue Cross and Blue Shield of Louisiana’s prescription
drug program is administered by Express Scripts,
Inc., which is an independent company. Most major
retail pharmacies across the nation participate in our
pharmacy network. To fill a prescription, members
simply present their ID card to an Express Scripts
NOTE: Specialty drugs may be limited to
a 30-day supply.
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®
®
trueBLUE
Benefits
Prior Authorization
Certain prescription drugs and supplies require prior
authorization. Please check your Schedule of Benefits,
visit the website at www.bcbsla.com or call the
Customer Service number on the back of your ID card to
see what drugs and supplies require prior authorization.
• Owner 24-Hour Coverage
• Accidental Injuries
• Organ, Tissue and Bone
Marrow Transplant Benefits
• Mental and Nervous /
Substance Abuse
• Pregnancy Care
• Cafeteria Plans
• Care Management Programs
• Customer Service
• Value-Added Services
®
Owner 24-Hour Coverage
For the protection of employers, Blue Cross offers
coverage for occupational injuries and diseases
for qualified company owners. Coverage for services
that are required to be covered in whole or in part
by Workers’ Compensation insurance is also
available for owners, if the owner complies with
La. R.S. 23:1035(A).
Accidental Injuries
Blue Cross and Blue Shield of Louisiana includes
coverage for accidental injuries up to a maximum
benefit of $350 per benefit period, not subject to
benefit period deductible or coinsurance. The first $350
of covered medical expenses from an accidental injury
will be covered at 100 percent of the allowable charge.
Once this maximum is exhausted, comprehensive
medical benefits will be paid, subject to benefit year
deductibles and coinsurance, for the remainder of that
benefit period.
®
Organ, Tissue and Bone Marrow
Transplant Benefits
Special Options
and Features
Eligible organ, tissue and bone marrow transplants
are covered. Members have access to the Blue Quality
Centers for Transplant, a network of major hospitals
and research institutions located throughout the
country. Patient care is coordinated with Blue Cross and
Blue Shield of Louisiana case management, physicians
and institutions. Eligible organ, tissue and bone
marrow transplants will be covered, including a $50,000
acquisition expense maximum. See the organ, tissue
and bone marrow transplant section of the benefit plan
or contract for complete details
and qualifications.
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Mental and Nervous /
substance Abuse
hospital stay. Our Care Management Department
works directly with the patient, the hospital and the
admitting physician to assess the continued necessity
of hospitalization. If a patient chooses to stay in the
hospital after it is determined to be unnecessary, he or
she will be responsible for all expenses incurred during
the remainder of the stay.
Coverage for Mental and Nervous/Substance Abuse is
paid the same as or better than any other illness. All
benefits are subject to any applicable deductible and
coinsurance and/or copayments (coinsurance applies
to the out-of-pocket maximum).
3. Case Management
Case Management is a special service performed at
the discretion of Blue Cross. Case Management
oversees the treatment of unusually complex, difficult
or lengthy illnesses. The case management staff, with
the member’s acceptance, can develop a long-term
treatment plan to achieve the most efficient, effective
use of medical resources.
Please refer to the quote sheet for specific option(s)
quoted and appropriate deductible, coinsurance and/
or copayment quoted for the group.
Pregnancy Care
Pregnancy care is automatically included for employees
and covered spouses in all group plans with 15 or more
employees. Groups with 14 or fewer employees on the
payroll can exclude pregnancy benefits if desired.
Miscarriages and ectopic pregnancies are covered
under medical and surgical benefits regardless of
whether the pregnancy option is chosen.
4. Authorization of Covered Services
Certain services and supplies require written
authorization from Blue Cross before services can be
performed. This allows our medical staff to review a
procedure or service and determine whether it is in the
best interest of the patient. Please see the Benefit Plan
and schedule of benefits for a list of services and
supplies that require prior authorization.
Please refer to the quote sheet for options quoted.
5. Retrospective Review
A retrospective review may be performed to assess
the medical need and correct billing level for services
that have already been rendered.
Customer Service
trueBlue is strengthened by our Care Management
programs that ensure your care is appropriate. Our team
of doctors, nurses and in-house pharmacists oversees
our members’ care through the following functions:
Your Answer is Just
a Click or a Call Away…
1. Authorization of Elective Admissions
Have a question about your claim? Want to know if
a service is covered under your plan? Get the answers
to your healthcare coverage questions using our new,
secure online Customer Inquiry Form.
If you need to be hospitalized for a condition other
than an emergency, your admission to the hospital
requires “authorization.” Patients, physicians, hospitals
and our Care Management Department all participate
in this process that is used to determine whether
hospitalization is necessary and an appropriate length
of stay. In the case of an emergency admission, written
authorization must be requested within 48 hours of the
admission by you or your provider.
This form allows you to submit questions to
our Customer Service Department securely and
conveniently – any time of day or night. Simply log
on to the Blue Cross website at www.bcbsla.com,
click on Customer, then choose Customer Inquiry Form.
Follow the directions on the screen to get started!
2. Concurrent Review
The process of determining whether continued hospital
care is appropriate, also called concurrent review,
will be conducted from time to time during a lengthy
You can always call us between 8 a.m. and 5 p.m.,
Monday through Friday, at 1.800.495.BLUE (2583).
This number is also listed on your member ID card.
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®
®
Special Options
and Features
Care Management
Programs
Financial Well-Being
Value-Added
Services
•Plan for Your Future – understanding Medicare-related
health insurance options and how they affect your
financial future
•Financial Resources – educational tools to prepare
for long-term healthcare needs
Travel
DISCOUNT FEATURES
•Healthy Getaways – special discounts on hotel
programs and services
• Worldwide Health Coverage – access to doctors and
hospitals across the globe
•Travel Tips – a wealth of online travel tips and
resources
Dental Discount Network
Members can take advantage of special discounts on
dental services. Members simply present their ID card
to one of the participating providers and immediately
receive significant savings. To find a discount provider,
visit www.bcbsla.com and click on Find a Doctor or
Hospital. Under the Online Louisiana Directory, click
on Search Our Directory. From the drop-down menu,
choose Discount Dental. Please note that these
services are not eligible for benefits under the
benefit plan.
Members can explore all the healthy choices through the
Wellness Discount link in AccessBlue at www.bcbsla.com.
My Health Commitment, our unique
workplace wellness program
It’s easy to overlook the critical link between your
employees’ health and your company’s bottom line.
Blue 365®
Healthy employees can have a positive impact on:
Living well means having healthy options every day. That’s
why we offer Blue365® to take our members beyond health
insurance and give them access to trusted health and
wellness resources 365 days a year – and enjoy special
member values on many services.
• Healthcare costs
• Productivity
• Absenteeism
• Retention of quality personnel
• Employee quality of life
Blue365® is a national program that’s part of every
trueBlue plan, offering exclusive access to information,
discounts and savings, making it easier and more
affordable to make healthy choices.
My Health Commitment, our workplace wellness
program offered at no cost, gives your employees the
resources they need to live healthier – every day.
Health & Wellness
•Fitness – discounts on local health club memberships
and free access to online tools
•Diet/Weight Control – savings on programs, products
and consultations at Jenny Craig, eDiets and
NutriSystem.
•Vision Discounts — With Blue365® our members can
receive routine eye exams, frames, lenses,
conventional contact lenses and laser vision
correction at substantial savings when using Davis
Vision network providers. Members have access to
more than 30,000 providers nationwide, including
optometrists, ophthalmologists and many retail
centers. BCBSLA members can also save 40 to 50
percent off the overall national average price for
Lasik surgery through QualSight LASIK.
Built right into your Blue Cross health plan,
My Health Commitment includes:
• Personal Health Assessments
• Healthy lifestyle resources
• Wellness trackers
• Regional wellness events
• Local resource listings
• Discount programs
• And more!
For employers who want to expand their wellness
offering, we offer upgrades to the core program
listed above.
Family Care
For more information about My Health Commitment,
talk to your producer or visit us at www.bcbsla.com.
• Senior Care — discounts on care advisory services
• Child Safety – resources for child safety and consumer
product information
• Long-Term Insurance – free guidelines and information
•Managing Medicare – resources to understand
coverage options from Medicare
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Sometimes referred to as
a Section 125 Cafeteria plan,
a Flexible Spending Account
lets employees set aside a certain
amount of each paycheck into
an account – before paying
income tax.
The participant can use the account to pay for
out-of-pocket expenses at the doctor or pharmacy,
chiropractic, eyeglasses, contacts, Lasik, orthodontics
and more.
Advantages of an FSA for Employers
• Save on payroll taxes — approximately 8 percent
on every dollar employees set aside.
• Cushion health insurance increases to lessen the
impact on employee’s paycheck.
• Plan fees can be paid by employer or employee.
Participants and employers can view and manage their
flex accounts online at their convenience. The standard
Flexible Spending Accounts include a Premium-Only
Plan, Medical Reimbursement Account and Dependent
Care Plan.
Premium-Only Plan
®
®
Medical Reimbursement
• This account allows participants to set aside money
from each paycheck for the reimbursement of
medical expenses of a dependent child under age 13.
Dependent Care Plan
• Employees set aside pre-tax payroll deductions to
budget for the daycare expenses of a dependent
child under age 13.
You can review our entire Flexible Spending Account
offerings plan online at www.ezflexplan.com/snl/.
Our online resource provides employers with plan
options, advantages to employees and numerous
administrative tools. Once enrolled in our FSA,
employers and employees can view and manage their
flex accounts at their convenience.
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®
Cafeteria Plan
Cafeteria
Plan
• The Section 125 Premium Only Plan saves you and
your employees by reducing payroll taxes. It works
by making one simple adjustment in your payroll
process: Employees pay their portion of insurance
premiums on a pre-tax basis. Qualifying premiums
may include an employee’s share of employersponsored health, dental, disability, accident and
group term life insurance.
®
• Eligible Groups
• Eligible Employees
• Eligible Dependents
• Group Rates
• Renewability
• Coordination of Benefits
• Health Questions
• Prior Group Coverage
• Special Enrollment
• Late Enrollee
• Benefit Plan Limitations
and Exclusions
Eligible Groups
All groups with two or more employees are eligible
to apply for coverage. There are no industry
restrictions. Firms that have been in business less
than one year are subject to home-office rating
and approval. Firms that do not have a current carrier
or are seasonal also are subject to home-office
rating and approval. In some cases, firms with
a significant number of employees living outside
of Louisiana may not be eligible.
If a firm chooses a contributory plan, at least 75 percent
of its full-time eligible employees must participate.
For non-contributory plans, 100 percent participation
is required. These percentage requirements are for
the initial and ongoing enrollment. Other specific
conditions that may apply are contained within the
group master application.
Eligible Employees
®
All full-time employees working a minimum of
30 hours per week and their qualified dependents
may apply. Individuals on retainer (examples:
attorneys, accountants, business consultants and
1099 contract employees) and members of boards
of directors are not eligible.
®
General
Conditions
Eligible employees, their eligible spouses and their
eligible dependents cannot be individually denied
coverage for any reason related to health status. If
health question responses are requested by Blue Cross,
they will be used for group rating purposes.
The effective date of coverage or benefit change will
not be delayed because an employee is not actively at
work due to health status.
Exclusions for pre-existing conditions may apply.
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Renewability
All benefit plans are renewable at the employer’s
option, except in the cases of:
• nonpayment of premium
• fraud or misrepresentation
• noncompliance with plan provisions, including
not meeting minimum participation and eligibility
requirements
• termination of all employer plans in that class of
business (90 days’ advance notice will be given)
The employer or Blue Cross may terminate the benefit
plan with 60 days’ advance notice.
Eligible Dependents
Insured employees may cover their spouses. They also
may cover their children and grandchildren as long as
they are under 26 years of age. For grandchildren to
be eligible, they also must reside with, and be in legal
custody of, the employee.
Coordination of Benefits
Coordination of benefits will be conducted when
a participant has additional group coverage. This
provision helps keep premiums low by preventing
duplicate payments for the same services.
Children (and grandchildren in legal custody of and
residing with the employee) who are mentally
or physically disabled also are eligible for coverage.
They must be incapable of self-support and enrolled
prior to reaching age 26. They must also continue to
meet the disability criteria.
Health Questions
See Benefit Plan for details on other dependents who
may qualify.
Group Rates
Rates may increase after the first 12 months and every
six months thereafter due to factors including, but not
limited to:
Prior Group Coverage
• demographic changes of the group, including
age changes
When the employer is replacing another group insurer,
Blue Cross adheres to all replacement requirements.
Credit will be given for any time served toward a waiting
period for pre-existing conditions. This applies to
employees listed on the current invoice of the previous
insurer. If an employee declines coverage for himself/
herself, spouse, or dependent child(ren) because
of certain other health insurance coverage, he/she
may in the future be able to enroll himself/herself or
spouse, or dependent child(ren) in this health plan,
provided that a complete request for enrollment is
received within 30 days after the other coverage ends.
• claims experience of all groups in the
class of business
• a group’s claims experience, health status and
duration of coverage
• an overall rise in medical costs
• regulatory considerations
• changes to benefit plan design
However, rates may increase more frequently than
stated above as described in the benefit plan.
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®
General
Conditions
In groups with two to 19 employees, applicants and
any eligible dependents must answer all health
questions on the employee application form. In groups
with 20 or more employees, employees who apply
after the group’s initial eligibility period can apply
within 30 days prior to the group’s anniversary date
and must answer all health questions on the employee
application form. These questions will not be used to
reject the application.
®
PPO 80/20
(60/40
out-ofnetwork)
$
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benefit Summary chart
$250
$1,500
$1,000 $2,500
√
√
$500
$2,250 $2,000$4,000
$750 $3,000
1,000 Late Enrollee
In addition, if an employee gains a new dependent as
a result of marriage, birth, adoption, or placement for
adoption, he/she may be able to enroll himself/herself,
spouse, and dependent child(ren) in this plan, provided
a complete request for enrollment is received within
30 days after marriage, or within 30 days after birth,
adoption, or placement of adoption.
A “late enrollee” is an eligible employee, spouse
or dependent child(ren) who:
• does not enroll for group health insurance
coverage when first eligible, and
• does not meet the qualifications of
a “special enrollee.”
Special Enrollee
An eligible employee must be covered in order to add
a spouse or dependent(s). Late enrollees may apply
for coverage during the group’s open enrollment period
within 30 days prior to the group’s policy anniversary
date, but will have an 18-month exclusion period for
pre-existing conditions.
In certain circumstances, an employee may enroll
himself/herself or spouse, or dependent child(ren) in
this health plan. These circumstances include, but are
not limited to, the following:
• Loss of certain types of other coverage
• Acquiring a dependent
Please refer to the benefit plan for details on special
enrollment rights.
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Benefit Plan Limitations
and Exclusions
(See Benefit Plan for complete list.)
®
Limitations and exclusions include,
but are not limited to:
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General
Conditions
• charges exceeding the allowable charge
• investigational surgery or treatments
• sales tax (except on covered prescription drugs)
• interest
• infertility treatments
• fertility drugs
• cosmetic surgery or treatment
• weight reduction surgery and programs
• corrective eyeglasses or lenses
• contact lenses
• treatment of impotence
• custodial care
• services that are not medically necessary
®
Small Employer Notice
If the sole reason for termination is that Group’s
participation falls to less than two (2) employees
(there is only one (1) employee covered (or owner,
if covered), termination of Group coverage will be
effective on the Group’s next anniversary date.
Otherwise, termination for a reason addressed in this
paragraph will be effective after Group receives sixty
(60) days written notice as described below:
Change in Premium Amount
Premiums for this Benefit Plan may increase after the
Group’s first twelve (12) months of coverage and every
six (6) months thereafter, except when premiums may
increase more frequently as described in the following
paragraph. Except as provided in the following
paragraph, We will give Group forty-five (45) days
written notice of any change in premium rates (ninety
(90) days written notice for employer groups with more
than one-hundred (100) enrolled employees). We will
send notice to the Group’s latest address shown in Our
records. Any increase in premium is effective on the
date specified in the rate change notice. Continued
payment of premium will constitute acceptance of the
change.
•In the case of Network plans, there is no longer any
enrollee under the Group benefit plan that lives,
resides, or works in the service area of the Company
or in the area for which the Company is authorized to
do business.
•Group’s coverage is provided through a bona fide
association and the employer’s membership in the
association ends.
•Company ceases to offer this product or coverage in
the market.
We reserve the right to increase the premiums more
often than stated above due to a change in the extent
or nature of the risk that was not previously considered
in the rate determination process at any time during
the life of the Benefit Plan. This risk includes, but is not
limited to, the right to increase the premium amount
because of: (1) the addition of a newly covered person;
(2) the addition of a newly covered entity; (3) a change
in age or geographic location of any individual insured
or policyholder; (4) or a change in the policy Benefit
level from that which was in force at the time of the
last rate determination. An increase in premium will
become effective on the next billing date following
the effective date of the change to the risk. Continued
payment of premium will constitute acceptance
of the change.
Renewability of Coverage
Company may terminate this Benefit Plan if any one of
the following occurs:
•Group commits fraud or makes an intentional
misrepresentation.
•Group fails to comply with a material plan provision,
including, but not limited to provisions relating
to eligibility, employer contributions or Group
participation rules.
16
NOTES
17
NOTES
18
Sales OFFICES
Alexandria
318.448.1660
4508 Coliseum Boulevard, Suite A
Alexandria, Louisiana 71303
Baton Rouge
225.295.2556
5525 Reitz Avenue
Baton Rouge, Louisiana 70809-3802
Houma
985.223.3499
1437 St. Charles Street, Suite 135
Houma, Louisiana 70360
Lafayette
337.593.5727
5501 Johnston Street
Lafayette, Louisiana 70503
Lake Charles
337.562.0595
219 West Prien Lake Road
Lake Charles, Louisiana 70601-8450
Monroe
318.323.1479
3130 Mercedes Drive
Monroe, Louisiana 71201
New Orleans
504.832.5800
3501 North Causeway Boulevard, Suite 600
Metairie, Louisiana 70002
Shreveport
318.795.0573
411 Ashley Ridge Boulevard
Shreveport, Louisiana 71106
Customer Service
Baton Rouge
800.495.2583
[email protected]
5525 Reitz Avenue
Baton Rouge, Louisiana 70809-3802
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company