Medical Benefits

The Blue Cross Community MMAI plan covers many of your health care needs. You pay nothing ($0) when you go to a doctor or health care provider in the plan's network.

Services must be medically necessary. Some services need approval from your health plan before you get treated. This approval is called "preauthorization." Your doctor should know which services need approval and can help with the details.

What is covered?

Here are just some of the services covered under this plan:

Services You May NeedYour Cost for In-Network ProvidersRules About Benefits
Ambulance Services $0 Preauthorization is not required.

You may go to any emergency room if you reasonably believe you need emergency care.
Care to keep you from getting sick, such as flu shots $0 Preauthorization is not required for services provided by in-network providers.
Doctor Visits:
  • To treat an injury or illness
  • Specialist care
  • Wellness visits, such as an annual physical
$0 Preauthorization is not required for services provided by in-network providers.
Durable Medical Equipment
(including Oxygen)
$0 Preauthorization required for Durable Medical Equipment (DME) greater than $2,500. Other preauthorization rules may apply. For a detailed list, call Member Services.

You must use in-network providers.
Emergency Room Service $0 Preauthorization is not required.

Not covered outside the U.S. and its territories, except under limited circumstances. Contact plan for details.

You may go to any emergency room if you reasonably believe you need emergency care.
Hearing Screenings and Hearing Aids $0 Preauthorization rules may apply.

You must use in-network providers.

Hearing aids and fitting/evaluation: allowed 1 per ear every 3 years.
Home Health Care $0 Preauthorization rules may apply.

You must use in-network providers.
Hospital Stay $0 Preauthorization rules may apply, except in an emergency. Your doctor must tell the health plan that you are going to be admitted to the hospital.

You must use in-network hospitals when not an emergency.
Medical Tests:
  • Lab Tests, such as blood work
  • Screening Tests, such as tests to check for cancer
  • X-rays or other pictures, such as CAT scans
$0 Preauthorization rules may apply.

You must use in-network providers.
Mental or Behavioral Health Services $0 Preauthorization may be required. For a detailed list of services that require a preauthorization, please call Member Services.

You must use in-network providers.
Transportation to a doctor's office $0 Preauthorization rules may apply.

You must use in-network providers.
Urgent Care $0 Preauthorization is not required

Urgent care is not covered outside of the United States and its territories.

If you require urgently needed care, you should first try to get it from a network provider or call our 24/7 Nurse Advice Call Line. However, you can use out-of network providers when you cannot get to a network provider.

For a complete list of covered services, see the Summary of Benefits Link to Member Handbook PDF.

What is not covered?

Some services that are not covered include:

  • Cosmetic surgery or treatment
  • Experimental procedures
  • Infertility treatment
  • Services by non-licensed providers
  • Services provided without a required referral or preauthorization

To learn more about medical benefits, see the Member Handbook Link to Member Handbook PDF.

 

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