3. bluecrosswisconsin.com
BENEFITS
WAITING PERIODS A condition which manifests itself in the 6 months
before the member’s effective date. No benefits are
payable for a pre-existing condition until one of the
following: 12 consecutive months after the
effective date during which no care was received or
during which the member was insured under this
contract. Portability applies.
DEPENDENT
ELIGIBILITY
Dependents to 19, end of year
Full-time students to age 23, end of year
4. bluecrosswisconsin.com
BENEFITS CONTINUED
DEDUCTIBLE
(Option A, B available)
No 4th
Quarter Carryover.
Includes common accident.
A. $500 (single)
$1,500 (family)
IN/OUT Network combined aggregate.
Family aggregate, 3 times the individual.
B. $1,500 (single)
$4,500 (family)
IN/OUT Network combined aggregate.
Family aggregate, 3 times the individual.
5. bluecrosswisconsin.com
BENEFITS CONTINUED
COINSURANCE A. In/Network: 80%/20% of $7,500 (single),
100% after
80%/20% of $22,500 (family),
100% after
Out/Network: 50%/50% of $9,000 (single),
100% after
50%/50% of $27,000 (family),
100% after
B. In/Network: 80%/20% of $5,000 (single),
100% after
80%/20% of $15,000 (family),
100% after
Out/Network: 60%/40% of $10,000, (single),
100% after
60%/40% of $30,000, (family),
100% after
6. bluecrosswisconsin.com
BENEFITS CONTINUED
COINSURANCE
OUT-OF-POCKET
MAXIMUM
(per calendar year, does not
include deductible)
level 1 and level 2 accumulate
separately under the out-of-
pocket maximum
A. In/Network: $1,500 out of pocket maximum
(single)
$4,500 out of pocket maximum
(family)
Out/Network: $4,500 out of pocket maximum
(single)
$13,500 out of pocket maximum
(family)
B. In/Network: $1,000 out of pocket maximum
(single)
$3,000 out of pocket maximum
(family)
Out/Network: $4,000 out of pocket maximum
(single)
$12,000 out of pocket maximum
(family)
LIFETIME MAXIMUM $1,000,000
7. bluecrosswisconsin.com
INPATIENT HOSPITAL
SERVICES
INPATIENT HOSPITAL
DAY MAXIMUM
Unlimited inpatient days, per member, per
confinement - including accommodations and
ancillary services.
Discharge and re-admission equals new
confinement.
Subject to deductibles and coinsurance.
ACCOMMODATIONS Average Semi-Private room
8. bluecrosswisconsin.com
OUTPATIENT
HOSPITAL SERVICES
EMERGENCY ACCIDENT
CARE/
EMERGENCY MEDICAL
CARE/
ILLNESS
In/Network: $100 / Out/Network: $150 copay for
Emergency outpatient hospital charge (per visit) -
Waived if admitted or related to a surgical
procedure.
Additional services related to the emergency/clinics
room/clinics stay are subject to any applicable
deductibles and coinsurance.
DIAGNOSTIC, XRAY &
LAB
(Includes mammograms)
Subject to deductibles and coinsurance.
(2 mammograms between 45-49 years of age, one
per year 50+)
9. bluecrosswisconsin.com
SURGICAL
PROFESSIONAL
SERVICES
SURGERY Subject to deductibles and coinsurance.
STERILIZATIONS Subject to deductibles and coinsurance.
ELECTIVE/ THERAPEUTIC
ABORTIONS
Subject to deductibles and coinsurance.
ASSISTANT SURGEON Subject to deductibles and coinsurance.
ORGAN TRANSPLANTS
(365 day waiting period for all
transplants other than kidney
will apply)
Kidney, cornea, heart, lung, heart/lung, liver,
pancreas, and non-experimental/investigational
bone marrow.
Subject to deductibles and coinsurance.
10. bluecrosswisconsin.com
MEDICAL
PROFESSIONAL
SERVICES
INPATIENT GENERAL
MEDICAL CARE &
CONSULTATIONS
Subject to deductibles and coinsurance.
HOME, OFFICE,
OUTPATIENT VISITS
& CONSULTATIONS
Subject to deductible and coinsurance.
CHIROPRACTOR Subject to deductible and coinsurance.
ACCIDENT
CARE/URGENT CARE
Subject to deductibles and coinsurance.
11. bluecrosswisconsin.com
MEDICAL
PROFESSIONAL
SERVICES
CONTINUED
CHILDHOOD
IMMUNIZATION
(As of 11/01/00)
The in-network benefit is not
subject to the plan's
deductible, coinsurance,
copayment or $500 routine
maximum. For OON, the
normal plan cost-sharing
requirements apply.
Benefits are available to dependents under 6 years
of age for appropriate and necessary
immunizations. “Appropriate and necessary
immunizations” means the administration of
vaccine that meets the standards approved by the
U.S. public health services for such biological
products against at least all of the following:
diphtheria, pertussis, tetanus, polio, measles,
mumps, rubella, hemophilus influenza B, hepatitis
B, varicella.
12. bluecrosswisconsin.com
PROFESSIONAL
THERAPY SERVICES
(Includes Inpatient &
Outpatient)
CHEMOTHERAPY,
RADIATION, &
DIALYSIS
All forms chemotherapy, full radiation.
Subject to deductibles and coinsurance.
PHYSICAL THERAPY,
SPEECH,
RESPIRATORY, &
OCCUPATIONAL
THERAPY
Subject to deductible and coinsurance.
15. bluecrosswisconsin.com
OTHER SERVICES
MATERNITY
(Includes prenatal/postnatal
care and delivery)
Subject to deductibles and coinsurance.
Benefits for a hospital stay following the birth of a
child will not be less than 48 hours for a vaginal
delivery and 96 hours for a cesarean section.
HOME CARE 40 visits per calendar year, additional 40 if
terminally ill.
Subject to deductibles and coinsurance.
SKILLED NURSING
FACILITY
30 days per admission
Subject to deductibles and coinsurance.
PRE-CERTIFICATION
PROGRAM
Advantage Program in effect
$500 penalty for non-compliance with pre-
certification requirements. Does not apply towards
deductibles, coinsurance, or any applicable
copayment.
16. bluecrosswisconsin.com
OTHER SERVICES CONTINUED
MENTAL
HEALTH/ALCOHOLISM
OR OTHER DRUG
ABUSE – INPATIENT
$7,000, lesser of 30 days or $7,000 minus 10%.
Not subject to deductibles and coinsurance.
Once the maximum is met, one additional Inpatient
day of care, is available for mental health at 100%.
This benefit does not include services rendered for
the treatment of alcoholism or other drug abuse
problems.
MENTAL HEALTH –
TRANSITIONAL
DRUG AND
ALCOHOLISM
Subject to $3,000 maximum minus 10%
coinsurance.
Not subject to deductible and coinsurance.
Once the maximum is met, one additional
Transitional treatment, is available for mental
health at 100%. This benefit does not include
services rendered for the treatment of alcoholism or
other drug abuse problems.
17. bluecrosswisconsin.com
MENTAL HEALTH –
OUTPATIENT OFFICE
VISIT DRUG AND
ALCOHOLISM
Subject to $2,000 maximum minus 10%
coinsurance.
Not subject to deductible and coinsurance.
Once the maximum is met, one additional
Outpatient visit, is available for mental health at
100%. This benefit does not include services
rendered for the treatment of alcoholism or other
drug abuse problems.
ROUTINE CARE
(Physical exams, well baby,
and immunizations over age
6. Includes related DXL.
Includes physical exams for
sports, school, employment,
occupation, & insurance.)
Paid at 100% with $500 annual maximum per
person.
(Only in network.)
18. bluecrosswisconsin.com
MENTAL HEALTH –
OUTPATIENT OFFICE
VISIT DRUG AND
ALCOHOLISM
Subject to $2,000 maximum minus 10%
coinsurance.
Not subject to deductible and coinsurance.
Once the maximum is met, one additional
Outpatient visit, is available for mental health at
100%. This benefit does not include services
rendered for the treatment of alcoholism or other
drug abuse problems.
ROUTINE CARE
(Physical exams, well baby,
and immunizations over age
6. Includes related DXL.
Includes physical exams for
sports, school, employment,
occupation, & insurance.)
Paid at 100% with $500 annual maximum per
person.
(Only in network.)
19. bluecrosswisconsin.com
AMBULANCE Services limited to $200 per trip.
Not subject to deductible and coinsurance.
OTHER SERVICES CONTINUED
BLOOD Covered from 1
st
pint.
Subject to deductible and coinsurance.
LEAD SCREENING Subject to deductibles and coinsurance, (up to age
6).
PROSTHETICS AND
DURABLE MEDICAL
EQUIPMENT
Subject to deductibles and coinsurance.
MEDICAL SUPPLIES Subject to deductibles and coinsurance.
HOLD HARMLESS None
20. bluecrosswisconsin.com
EXCLUSIONS PPO does not provide coverage for the following: Routine or
administrative physical exams out-of-network, except
mammographies. Hearing aids. Dentistry, including treatment
for temporomandibular joint (TMJ) disorders, except as
specifically described in the policy. Cosmetic surgery, unless
needed as a result of an accident, to correct a birth defect, or
for breast reconstruction following a mastectomy. Weight-loss
programs, except as covered under the wellness program.
Orthodontics, orthognathic surgery and osteotomies. Illness or
injury eligible for workers compensation. Services for which
an individual is eligible under Medicare, whether or not the
individual is enrolled in Medicare. (continued)
21. bluecrosswisconsin.com
EXCLUSIONS
CONTINUED
Services considered not medically necessary or
experimental/investigational. Services performed by an
immediate family member or someone who lives with the
patient. For organ or bone marrow transplants other than:
kidney, cornea, non-experimental/investigational bone marrow,
including hematopoietic stem cell support, heart, lung,
heart/lung, liver and pancreas. Inpatient hospitalization
primarily for physical, x-ray and radiation therapies. Any
infertility treatment. Reversal of sterilization. Any portion of a
charge for a specific service that is greater than the usual and
customary allowance in that area.
UWG LIFE
BENEFIT
Life Insurance Benefits to be underwritten by United Wisconsin
Group. $10,000, Life, $200 STD.
8/23/00
22. bluecrosswisconsin.com
Buy Direct PPO
Plan A
Plan B
1 MM Lifetime Max
PPO ER-Copay/$100
Non-PPO ER-Copay/$150
Full-time students to age 23
Family Aggregate-3X Individual
Routine Care w/out office visit
Copay
2 to 99
Option 1
Option 2
2 MM Lifetime Max
PPO ER-Copay/$50
Non-PPO ER-Copay/$75
Full-time students to age 26
Family Aggregate-2X Individual
Routine Care w/office visit Copay
Product Variations
