2016 Traditional Care Network (TCN)
Benefits at a glance for Ford UAW Trust members
Group Number: 71435
Traditional Care Network
ms/definitions
Hospital care
Call/nursing telephone support
Hospital and other services
Alternatives to hospital care
Plan benefits
Ready to join
Maternity care
Who can join
You have many options when it comes to choosing health care. Thank you for choosing Medical
Mutual of Ohio.
and other services
es to hospital care
nal medicare
Plan benefits
Ready to join
Maternity care
Other services
Mental health and substance abuse
treatment
Questions
Leaving the hospital
DME
We offer the Traditional Care Network (TCN) health plan to retired non-Medicare members.
Who can join
Organ transp
Member
Physicians/Providers
As a member of the UAW Retiree Medical Benefits Trust, you can choose the plan that meets your
needs and those of your family. The plan offers you all the great benefits that come with being
an MMO member.
he hospital
Questions
DME
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Eye car
Organ transplant
Member
There is always extra value when you choose MMO. With every MMO card, you receive additional support.
Some of the programs we offer members include:
Important terms/definitions
com/online/live
n drugs
MyBlue Medicare Magazine
Deductible, coinsurance and dollar
maximums
Important terms/definitions
Hospital care
Physician office services
Reasons to join
Hospital care
Physicians/Providers
Call/nursing telephone support
Outpatient diagnostic services
Surgical services
Call/nursing telephone support
Beyond original medicare
Tobacco
cessation
Surgical
services
heart failure or COPD
SilverSneakers
Facing a complex medical condition
Customer service
Ready to join
hearing
Hospital and other services
Alternatives to hospital care
care
PlanEye
benefits
Ready to join
Other services
Emergency
hearing services
Shot
Who can join
Pneumonia
Customer service
Mental health and substance abuse
Leaving the hospital
treatment
Coping
with heart failure or COPD
Facing a complex medical condition
Questions
DME
Where am i covered
Who can join
Research monitors
Case Management solutions that assist with medical issues, give you access to
experts who can coordinate treatments, and provide
guidance and support.
Questions
Other services
Mental health and substance abuse
Leaving the hospital
DME
treatment
You can call 1-800-258-3175 for direction.
Shot
Beyond original medicare
Plan benefits
Our SuperWell Quit Line that teaches you self-management and coping skills for
smoking intervention and cessation. You can call 1-866-845-7702 to get started.
Missouri
s
diagnostic
services
Missouri
Hospital and other services
Alternatives to hospital care
Where am i covered
Pneumonia
Preventive care
Member
Physicians/Providers
Prescription drugs
Research monitors
Deductible, coinsurance and dollar
maximums
Reasons to join
Physicians/Providers
Online health resources at bcbsm.com that include more than 90,000 medically
reviewed resources in a number of formats, such as:
Missouri
SilverSneakers
Internet/bcbsm.com/online/live
coaching
Preventive care
Prescription drugs
– libraries, encyclopedias and directories
MyBlue Medicare Magazine
Physician office services
Outpatient diagnostic services
Deductible, coinsurance and dollar
Surgical servicesmaximums
Customer ser
Reasons to join
hearing
Shot
– videos, calculators, podcasts, and animations
Pneumonia
Missouri
– decision making guides and interactive quizzes
Internet/bcbsm.com/online/live
Everyday savings
coaching
MyBlue Medicare Magazine
Tobacco cessation
Physician office services
Emergency services
Outpatient diagnostic services
Coping with heart failure or COPD
Surgical services
Facing a complex medical condition
hearing
Where am i covered
Research monitors
SuperWell Extras programs for discounts on fitness (call 1-888-636-3621) and
Weight Watchers (call 1-866-204-2878).
Everyday savings
2
Tobacco cessation
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Shot
Pneum
Research monitors
With the Traditional Care Network product (referred to as TCN), you have access to the largest network
of doctors, hospitals, and other health care providers from which to choose within our preferred provider
care organization (PPO).
Our large network gives your family access to thousands of doctors and hospitals. More than likely, any
doctor or hospital you choose will be in the network.
Along with our expansive network, you will usually pay less when you use a network provider. Deductibles,
co-insurance, copayments, and overall out-of-pocket expenses are less when you choose to use a
network provider. If you go outside of the vast network of providers, however, you will have to pay more
for services.
It’s easy to check to see if your provider is in the network by calling customer service at 1-888-636-3621
or going to medmutual.com and Individuals and families, under “Find A Doctor.”
If you ever have any questions about
• your coverage
• bills you may have received
• your explanation of benefits
contact customer service at 1-888-636-3621. You can always find that number on the back of your card.
Customer service representatives will be happy to answer any questions you may have.
Thank you for being a member of Medical Mutual of Ohio. Thank you for choosing the Traditional
Care Network product.
3
D
Plan benefits
Ready to join
Maternity care
2016
Questions
Benefits at a glance with
cost sharing summary
Who can join
DME
Organ transplant
Monthly contribution and
out-of-pocket expenses
Member
You pay
Physicians/Providers
Reasons to join for General Retiree
Monthly contribution
and Surviving Spouse — The monthly amount you must pay
Deductible, coinsurance and dollar
maximums
In network
Eye care
Individual: $17
Family: $34
Missouri
Customer service
in order to have coverage for yourself
and your dependents
Individual: $0
Family: $0
Monthly contribution for Protected Retiree
and
Surgical
servicesSurviving Spouse
hearing
Shot
Pneumonia
Deductible – per calendar year
Facing a complex medical condition
Where am i covered
Out of network
Research monitors
Individual: $385
Individual: $1,000
Family: $650
Family: $1,700
Protected Individual/ Protected Individual/
Family: $0
Family: $0
10%
Coinsurance
Protected Individual/ Protected Individual/
Family: $0
Family: 10%
Individual: $3,000
Family: $5,550
Family: $1,395
Protected Individual/
Family: Unlimited
Protected Individual/
due to 10% on-going
Family: $0
copay
Individual: $755
Out‑of‑pocket maximum – per calendar year
Combination of deductible and coinsurance
4
30%
Understanding important terms
Important terms/definitions
Hospital care
Call/nursing telephone support
Hospital and other services
Alternatives to hospital care
Beyond original medicare
Other services
Mental health and substance abuse
treatment
Leaving the hospital
Plan benefits
Ready to join
Insurance pays 100%
Out-of-pocket
maximum met
Questions
DME
$$$
Coinsurance
SilverSneakers
Preventive care
Deductible met
Internet/bcbsm.com/online/live
coaching
MyBlue Medicare Magazine
Prescription drugs
(you andDeductible,
insurance
coinsurance and dollar
maximums
share cost)
Reasons to join
$$
Physician office services
Outpatient diagnostic services
Surgical services
hearing
Deductible
(you pay)
Everyday savings
Tobacco cessation
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Deductible — The amount you must pay toward covered medical services within a calendar year before
the Plan begins to pay. This does not apply to services that require a copay.
Coinsurance — The percentage you pay for covered services after you have met your deductible.
Out-of–pocket maximum — The total amount you will pay in a calendar year. It is a combination of the
deductible and coinsurance. Once paid, all covered services are paid at 100% for the rest of the calendar year.
Copayment (copay) — A fixed amount you pay to receive a medical service, usually at the time the
service is performed (office visits, emergency room, urgent care). Note that the copayment does not
go toward paying the deductible, coinsurance or out-of-pocket maximum. Copays are separate and
continue even after your out-of-pocket maximums are met.
In-network providers — Providers (i.e., hospitals and doctors, etc.) that sign a contract agreeing
to accept the allowed amount for a service as payment in full so that members will not be billed for the balance.
Out-of-network providers — Providers (i.e., hospital and doctors, etc.) that have not signed a contract
to accept the approved amount and may bill for balances. Out-of-network providers may result in
higher out-of-pocket costs.
5
Who can join
2016 Benefits at a glance
Mental health and substance abuse
treatment
Leaving the hospital
Questions
DME
Organ transplant
Member
You pay
Physicians/Providers
Preventive services
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
In network
Out of network
Missouri– 100%
Covered
Covered – subject
to deductible and
coinsurance
Customer service
Reasons to join
Pap Smear Screening – one per calendar year
Protected – covered
subject to coinsurance
Outpatient diagnostic services
Surgical services
hearing
Mammography Screening
Routine and high-risk mammogram screening in
accordance with guidelines established by the American
Cancer Society – one routine exam per calendar year
beginning at age 40. Under age 40, one per calendar year,
if high-risk factors are present
Physician office services
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Prostate Specific Antigen (PSA) Screening
Screening test for asymptomatic males age 40 and older
when performed in accordance with guidelines established
by the American Cancer Society – one per calendar year
Shot
Covered – 100%
Pneumonia
Covered – subject
to deductible and
coinsurance
Protected – covered
subject to coinsurance
Research monitors
Covered – 100%
Covered – subject
to deductible and
coinsurance
Protected – covered
subject to coinsurance
Early Detection Screening Tests
Early detection screening for colon and rectal cancers
when performed in accordance with guidelines
established by the American Cancer Society.
Barium Enema X-ray — one every 5 years age 50 and over
(or at any age if risk factors are present); or
Colonoscopy — one every 10 years age 50 and over
(or at any age if risk factors are present); or
Covered – 100%
Not covered
Hepatitis C (HCV) Screening
For enrollees who are at risk or when signs or symptoms are
present which may indicate a Hepatitis C infection
Covered – 100%
Covered – subject
to deductible and
coinsurance
Well Baby – Six visits up to age 2
Covered – 100%
Not covered
Immunizations — age and frequency limitations for
selected medically recognized immunizations at doctor’s
office, retail health clinic, and certain immunizations at
a pharmacy.
Covered – 100%
Not covered
Not covered
Not covered
Sigmoidoscopy — one every five years age 50 and over
(or at any age if risk factors are present)
Fecal Occult Blood Test — one per calendar year
beginning at age 50
Total serum cholesterol with low density lipoprotein (LDL) —
one test every 5 years beginning at age 20
Bone Marrow Screening
6
Protected -- covered
subject to coinsurance
Eye care
Member
Physicians/Providers
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Eye care
Missouri
Physician office services
Call/nursing telephone support
Physician office services
Hospital and other services
Alternatives to hospital care
Outpatient diagnostic services
Plan benefits
Surgical services
Office Visits — not subject to deductibles or
FacingQuestions
a complex medical condiout-of-pocket maximums
tion
Emergency services
Coping with heart failure or COPD
Mental health and substance abuse
Leaving the hospital
treatment
Ready to join
You pay
In network
Customer service
Maternity care
Out of network
hearing
Non-Medicare members —
Covered
with $25 Pneumonia
Shot
Who can join
copayment for the first six
office visits to a Primary
Care Physician per year
per member. 100% member
Where am i covered
DME
monitors
copayment for Research
specialists
and subsequent office visits
at a discounted rate.
Not covered
Organ tra
Member
Physicians/Providers
Medicare members have
coverage through Medicare.
Preventive care
drugs
Deductible, coinsurance
Office
ConsultationPrescription
& Outpatient
Consultation
—and dollar
maximums
not subject to deductibles or out-of-pocket maximums
Covered at a 100% member
copayment for certain
procedure codes allowed at
discounted
Missouri rate
Reasons to join
Outpatient diagnostic services
Not covered
Protected -- Covered -100%
Surgical services
hearing
Shot
Emergency medical care
Pneumonia
You pay
In network
Emergency services
with heart
or COPD
Facing a complex medical
condiWhere am i covered
Hospital
EmergencyCoping
Room
—failure
Services
rendered
in the
tion
Covered –Research monitors
emergency room of a hospital for initial examination and
$125 copayment
treatment of condition resulting from accidental injury
waived
if admitted
or qualifying medical emergency are covered. Medical
emergencies will be considered to exist only if medical
Protected – covered 100%
treatment is secured within 72 hours after the onset of condition.
Physician — Qualified Medical Emergency & First Aid
Services: Initial examination and treatment of a
qualifying condition resulting from accidental injury or
qualifying medical emergency. Medical emergencies
will be considered to exist only if medical treatment is
secured within 72 hours after the onset of condition.
Urgent Care Centers
Ground Ambulance — medically necessary transport
Eye
Customer service
Covered – $50 copayment
Retail Health Clinics
Physician office services
Not covered
Covered – 100%
Covered – $50 copayment
Protected – covered 100%
Covered – subject to
deductible and coinsurance
Protected – covered 100%
Out of network
Covered –
$125 copayment
waived if admitted
Protected – covered
100%
Covered – 100%
Not covered
Covered – subject
to deductible and
coinsurance
Protected – covered
subject to coinsurance.
7
ort
abuse
Missouri
Customer service
2016 Benefits at a glance
Physician office services
Outpatient diagnostic services
Surgical services
hearing
Shot
Emergency medical care
Hospital and other services
Alternatives to hospital care
continued
Plan benefits
Pneumonia
You pay
In network
Ready to join
Out of network
Maternity care
Air/Water Ambulance
— Covers one-way
transport from
the
Coping with heart failure or COPD
Facing a complex medical condiWhere am i covered
Research monitors
scene of an emergency incident totionthe nearest available
facility qualified to treat the patient, or transporting a
Who can join
patient one-way or round-trip from home to the nearest
available facility qualified to treat the patient. Medical
Covered – 100% up to the
Covered – 100% up to
emergency/accidental injury patients are provided oneallowed
amount
the allowed amount
Questions
Leaving
hospital
waythe transportation
from home toDME
the facility. Home bound
Organ transplant
patients are provided round trip transportation from home
to the facility and back when medically necessary and
Member
Physicians/Providers
when other means of transportation could not be used
without endangering the patient’s health.
Emergency services
Medical Emergency/Accidental Injury: Follow-Up Care
Prescription drugs
Deductible, coinsurance and dollar
maximums
Missouri
Customer service
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Other Outpatient Diagnostic Tests, X-rays, Laboratory
& Pathology, PET, CAT Scans and Nuclear Medicine
Preauthorization may be required.
Radiation Therapy — for the diagnosis of condition,
disease or injury.
Preauthorization may be required.
Covered – subject to
deductible and
coinsurance
provided by a physician
Protected – covered 100%
Research monitors
Covered – subject to
deductible and
coinsurance
Protected – covered 100%
Covered – subject to
deductible and
coinsurance
Protected – covered 100%
Delivery and Nursery Care
In network
Covered – subject to
deductible and
coinsurance
Covered – subject to
deductible and
coinsurance
Protected – covered 100%
Eye care
ice
8
Protected – subject to
coinsurance
Covered – subject to
deductible and
coinsurance
Protected – subject to
coinsurance
Covered – subject to
deductible and
coinsurance
Protected – subject to
coinsurance
You pay
Protected – covered 100%
Organ transplant
Covered – subject to
deductible and
coinsurance
Pneumonia
Maternity services
Pre-Natal and Post-Natal Care
Out of network
hearing
Preauthorization may be required.
Maternity care
You pay
In network
Outpatient Magnetic Resonance Imaging (MRI),
Magnetic Resonance Angiography (MRA)
Shot
Use of MRI for diagnostic examination for all body parts
when ordered by a physician and performed on approved
equipment. Must be performed at approved facilities.
Surgical services
Not covered
Eye care
Diagnostic services
Outpatient diagnostic services
Not covered
Reasons to join
Out of network
Covered – subject to
deductible and
coinsurance
Protected – subject to
coinsurance
Covered – subject to
deductible and
coinsurance
Protected – subject to
coinsurance
ice
Maternity services continued
You pay
provided by a physician
In network
Maternity care
Out of network
Covered – subject to
deductible and
coinsurance
Abortions — must be medically necessary.
For medically induced abortion by oral ingestion of
medication when medically necessary
Protected – covered 100%
Certified
Nurse Midwife
Organ transplant
For a given uncomplicated pregnancy, reimbursement
for such care would be to the physician or certified nurse
midwife, but not both. Obstetrical services by certified nurse
midwives are limited to basic antepartum care, normal
care
vaginalEyedeliveries,
and postpartum care. Certified nurse
midwives are reimbursed only for deliveries occurring in
the inpatient setting or in a birthing center that is hospital
affiliated, state licensed and accredited and approved by
the carrier.
Covered – subject to
deductible and
coinsurance
Protected – covered 100%
Covered – subject to
deductible and
coinsurance
Protected – subject to
coinsurance
Covered – subject to
deductible and
coinsurance
Protected – subject to
coinsurance
The certified nurse midwife must be legally qualified and
registered, certified nurse and/or licensed, as applicable, to
perform these health care services.
You pay
Hospital care
Hospital care
Call/nursing telephone support
Hospital and other services
Alternatives to hospital care
In network
Plan benefits
Out of network
Ready to join
Covered – subject to
deductible and coinsurance
Who can join
Semi-Private Room, General Nursing Services,
Meals and Special Diets
Questions
Protected – covered 100%
(Predetermination required for non-Medicare members)
Other services
Mental health and substance abuse
treatment
Leaving the hospital
Covered for emergency
admissions only —
subject to deductible
and coinsurance
Maternity care
DME
Protected – covered
subject to coinsurance
Organ transplant
Maximum 365 days for each continuous period of
hospital confinement or for successive periods of
confinement separated by less than 60 days.
Member
Physicians/Providers
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Inpatient Medical Care
Covered – subject to
deductible and coinsurance
Missouri
Customer service
Protected – covered 100%
MyBlue Medicare Magazine
Physician office services
Outpatient diagnostic services
Surgical services
hearing
Chemotherapy
Coverage is provided for treatment of malignant disease
and Hodgkins disease, except when the treatment is
considered experimental or investigational.
Tobacco cessation
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Shot
Pneumonia
Covered – subject to
deductible and coinsurance
Protected – covered 100%
Research monitors
Covered – subject
to deductible and
coinsurance
Eye care
Protected – subject to
coinsurance
Covered – subject
to deductible and
coinsurance
Protected – subject to
coinsurance
9
port
e abuse
e
s
OPD
2016 Benefits at a glance
You pay
Alternatives to hospital care
Hospital and other services
Alternatives to hospital care
Plan benefits
Ambulatory Surgical Centers
(Facility must satisfy Program requirements and be an
approved facility)
Questions
Protected – covered 100%
Organ transplant
Member
Physicians/Providers
Deductible, coinsurance and dollar
maximums
Reasons to join
Surgical services
Facing a complex medical condition
Customer service
Protected – covered 100%
hearing
Hospice Care
(Provider approval required)
Coping with heart failure or COPD
Not covered
Limited to 100 days per
benefit period. Renewable
after 60 days of continuous
non-confinement.
Covered — subject to
deductible and coinsurance
Eye care
Missouri
Outpatient diagnostic services
Not covered
Protected – covered 100%
Covered — subject to
deductible and coinsurance
DME
Skilled Nursing Facility
(Must be an approved BCBS Skilled Nursing Facility)
Prescription drugs
Out of network
Maternity care
Who can join
Leaving the hospital
In network
Covered – subject to
deductible and coinsurance
Ready to join
Shot
Where am i covered
Pneumonia
Research monitors
Not covered
Limited to 2 days of hospice
care for each remaining
inpatient hospital day. Lifetime
maximum of 210 days.
Covered — subject to
deductible and coinsurance
Protected – covered 100%
Plan benefits
Ready to join
Limited to 3 home health
care visits for each remaining
day of the inpatient hospital
benefit period as long as the
patient is medically eligible.
Maternity care
Home Health Care
(Facility approval required)
Questions
Who can join
Each visit by member of the
home health care team, and
Organ transplant
each home health aide visit
is considered the equivalent
of 1 home visit.
DME
Member
Physicians/Providers
Deductible, coinsurance and dollar
maximums
Reasons to join
Eye care
Missouri
Customer service
Outpatient surgical services
Surgical services
hearing
Surgery — includes materials, supplies, preoperative and
Shot
Pneumonia
postoperative care, and suture removal
Facing a complex medical condition
Where am i covered
Research monitors
Voluntary Sterilization — excludes reversal sterilization
You pay
In network
Out of network
Covered – subject to
deductible and coinsurance
Covered – subject
to deductible and
coinsurance
Protected – covered 100%
Covered – subject to
deductible and coinsurance
Protected – covered 100%
10
Not covered
Protected – subject to
coinsurance
Covered – subject
to deductible and
coinsurance
Protected – subject to
coinsurance
Maternity care
e
You pay
Human organ transplants
In network
Out of network
Covered – subject to
deductible and coinsurance
Covered – subject
to deductible and
coinsurance
Organ transplant
Specified Organ Transplants
Preauthorization by Human Organ Transplant Program
is required. All members must be enrolled in case
management. Must be performed in a Blue
Distinction
Center.
Eye care
Call/nursing telephone support
Hospital and other services
Alternatives to hospital care
Plan benefits
Protected -- covered 100 %
Ready to join
Maternity care
Mental health care and
substance abuse treatment
Mental health and substance abuse
treatment
Protected -- covered
subject to coinsurance
Questions
Leaving the hospital
Who can join
You pay
In network
DME
Out of network
Inpatient:
Up to 45 days treatment
each for psychiatric
and substance abuse
covered — 100% up to the
allowed amount.
Inpatient:
Not covered unless
medical emergency
admission.
Organ transplant
Member
Physicians/Providers
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Eye care
Outpatient:
Mental Health: Up to 35 visits
covered per benefit period
— Visits 1-20: 100% up to
the allowed amount, Visits
21-35: 75% up to the allowed
amount.
Missouri
Customer service
Services must be preauthorized by ValueOptions.
For pre-authorization, call 1-877-228-3912 (not mandatory
for Medicare enrollees)
Physician office services
Outpatient diagnostic services
Surgical services
hearing
Shot
Emergency services
Coping with heart failure or COPD
Hospital care
Facing a complex medical condition
Call/nursing telephone support
Hospital and other services
Alternatives to hospital care
Where am i covered
Plan benefits
Pneumonia
Ready to join
Who can join
Other services
Allergy Testing
Other services
Mental health and substance abuse
treatment
Leaving the hospital
Substance Abuse:
Up to 35 visits per benefit
period covered at 100% up
to the allowed amount.
Research monitors
Questions
DME
Outpatient:
Mental Health: Up to 35
visits covered per benefit
period — Visits 1-20:
100% up to the allowed
amount, Visits 21-35: up
to 75% of the allowed
amount.
Substance Abuse:
Up to 35 visits per benefit
period covered at
100% up to the allowed
amount.
Maternity care
You pay
In network
Out of network
Not covered
Not covered
Organ transplant
Member
Covered subject to
deductible and coinsurance
Physicians/Providers
Allergy Therapy/Serum
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Protected -- covered at 100%
Missouri
Chiropractic Care
Emergency first aid and diagnostic x-ray of the spine only.
MyBlue Medicare Magazine
Physician office services
Outpatient diagnostic services
Surgical services
hearing
Excludes adjustment manipulation and initial office visit
Office and Outpatient Physical Therapy
(medical necessity required)
Tobacco cessation
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Customer service
Covered – subject to
deductible and coinsurance
Protected – covered 100%
Shot
Pneumonia
Covered subject
to deductible and
coinsurance
Protected -- covered
subject to coinsurance
Eye care
Covered – subject
to deductible and
coinsurance
Protected – subject to
coinsurance
Coverage is administered through
TheraMatrix, 1-888-638-8786
Research monitors
11
2016 Benefits at a glance
Hospital care
Call/nursing telephone support
Hospital and other services
Alternatives to hospital care
Plan benefits
Ready to join
Other services
Mental health and substance abuse
treatment
Leaving the hospital
You pay
Who can join
Other services continued
Questions
Maternity care
In network
DME
Out of network
Covered — subject to
deductible and coinsurance
Organ transplant
Protected – covered 100%
Member
Physicians/Providers
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Physician office services
Outpatient diagnostic services
Services are covered when
performed in the outpatient
department of the hospital
or approved freestanding
facility. Therapy is also
covered when provided by
an in-network independent
physical therapist, an
independent occupational
therapist, or speech and
language pathologist.
Missouri
Occupational and Speech Therapy
(medical necessity required)
MyBlue Medicare Magazine
Limited to 60 combined
visits per calendar year, per
condition.
Surgical services
hearing
Customer service
Shot
Tobacco cessation
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Durable Medical Equipment*
Prosthetic and Orthotic Appliances
Hair Pieces and Wigs — Wigs and appropriate related
supplies (stand and tape) are covered for any age for
an individual who is suffering hair loss from the effects of
chemotherapy, radiation therapy or other treatments for
cancer. For the initial purchase of wig and related supplies,
the maximum benefit is $250. Thereafter, the maximum
annual benefit is $125.
Prosthetic and Orthotic: Jaw Motion Rehabilitation
(Jaw motion rehabilitation system and related items)
Diabetes Education
Covers comprehensive American Diabetes Associationapproved education classes for newly-diagnosed or
uncontrolled diabetics.
Cardiac Rehabilitation – Only Phases I and II are covered
Must begin within 3 months of a cardiac event and be
completed within 6 months.
Eye care
Not covered
Pneumonia
Research monitors
Covered — 100%
Not covered
Covered — 100%
Prosthetic & Orthotic
appliances are not
covered with the
exception of wigs
Not covered
Not covered
Covered — 100%
Not covered
Up to 36 sessions
(3 sessions per week for
12 weeks) covered at 100%
up to the allowed amount
Not covered
*Durable Medical Equipment — Subject to deductible and coinsurance when processed as part of inpatient services or office services.
12
DME
aternity care
nd dollar
ondi-
use
Organ transplant
Member
Physicians/Providers
Reasons to join
Eye care
Hearing care
Missouri
Customer service
mustPlanbe
provider
benefitsa participating
Ready to
join
Hospital and other services
hearing
Alternatives
to hospital care
Organ transplant
Shot
Pneumonia
You pay
Maternity care
Hearing care administered by AudioNet, 1-877-500-7370
Who can join
Where am i covered
Research monitors
Vision care
You pay
Eye care
Vision care administered by SVS, 1-800-225-3095
Questions
Leaving the hospital
DME
Organ transplant
Member
Prescription drugs
Physicians/Providers
You pay
Coverage administered by Express Scripts 866-662-0274
Prescription drugs
Deductible, coinsurance and dollar
maximums
Retail
(One-Month Supply)
Mail Order
Outpatient diagnostic services
Surgical services
(90-Day Supply)
Tier 1: Generic $12
Reasons to join
Missouri
Customer service
Tier 3: Non-preferred Brand $100
Tier 1: Generic $24
Tier 2: Preferred Brand $80
hearing
Tier 3: Non-preferred Brand $200
Shot
Coping with heart failure or COPD
Eye care
Tier 2: Preferred Brand $40
Where am i covered
Prescription Drug
Categories
Facing a complex medical condition
Pneumonia
Research monitors
Tier 1: Generic Medications (Equivalents or Alternatives)
Important terms/definitions
Tier
(Single
Source,
Sensitive
Drug Classes)
Hospital2:
care Brand Medications
Call/nursing telephone support
Hospital
and other services Preferred
Plan benefitsBrand, andReady
to join
Alternatives to hospital care
Tier 3: Brand Medications (Multi-Source or Non-Preferred Brand)
Who can join
Beyond original medicare
Other services
Mental health and substance abuse
treatment
Leaving the hospital
Questions
DME
M
Physicians/Providers
SilverSneakers
Preventive care
Prescription drugs
Deductible, coinsurance and dollar
maximums
Reasons to join
Missouri
Internet/bcbsm.com/online/live
coaching
MyBlue Medicare Magazine
Physician office services
Outpatient diagnostic services
Surgical services
hearing
Shot
Everyday savings
Tobacco cessation
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Pneumonia
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Research monitors
Claim questions and appeals
1
To confirm you are paying the right
amount, compare the EOB and the
provider bill side-by-side. Match the
service dates and the amounts. If they
match, pay the provider that amount
and file the EOB for your records.
14
After your claims are submitted to MMO by your providers, you will receive an Explanation of
Benefits. In addition, you will most likely receive a billing statement from your provider, showing any
outstanding balances you may owe.
2
3
If the amounts do not match,
or if you have questions,
call customer service at
1-888-636-3621, as shown on the
back of your identification card.
A representative will be happy to
review the EOB statement and answer
your questions.
If you are not satisfied with the response
or outcome from customer service,
you may file an appeal. Call our
customer service center at 1-888-636-3621
for detailed directions.
4
5
If you want to file a first level appeal,
mail an explanation of
your concern and copies of the
statements in question to:
If the issue remains unresolved,
you may file an appeal with the UAW Trust.
Please see your Summary Plan for details.
Auto National Appeal Unit
600 Lafayette East — Mail Code 2004
Detroit, MI 48226-2998
15
Contact information
Medical Mutual of Ohio
ValueOptions – Help Line
Hospital, Surgical/Medical Services
For questions on benefits, claims or
how to locate providers
Precertification — Mental Health
and Substance Abuse
(required for non-Medicare members only)
1-888-636-3621
1-877-228-3912
Mailing Address (for claim inquiries):
National Provider Network
Medical Mutual
Information on network providers while traveling
P.O. Box 6018
Cleveland, Ohio 44101-1018
1-800-889-0277
Case Management
Express Scripts (formerly Medco Health)
Mail Order and Retail (Drug Stores)
Prescription drug questions
Coordination of health care
1-800-258-3175
1-866-662-0274
Retiree Health Care Connect
TheraMatrix
The UAW Trust eligibility and call center
Eligibility, membership, address changes,
and ID card requests.
Outpatient physical therapy
1-888-638-8786
1-866-637-7555
Delta Dental
SuperWell Quit Line
1-800-524-0149
for tobacco cessation
Davis Vision
1-866-845-7702
1-888-234-5164
Medicare
Veterans Health Administration
medicare.gov
va.gov/health
1-800-633-4227
1-877-222-8387
UAW Retiree Medical Benefits Trust
uawtrust.org
Medical Mutual of Ohio
is proudly represented by the UAW
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