Navigating your Good Health - for Chrysler Trust Members
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Preferred Provider Organization PPO
for Chrysler Trust Members
Navigating your Good Health
Blue Cross Blue Shield of Michigan
is a proud partner with the UAW
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent
licensee of the Blue Cross and Blue Shield Association.
2015 Benefits at a glance
Group#: 71434 – Chrysler
Provider Network: PPO (MI is BPP)
Monthly contribution Individual Family (two or more)
$17 $34
In network Out of network
Out-of-pocket expenses
Deductible — per calendar year $425 Individual $1,000 Individual
In-network and out-of-network deductibles $720 Family $1,700 Family
accumulate separately
Coinsurance 10% 30%
Out-of-pocket maximum — $1,200 Individual $3,000 Individual
per calendar year $2,220 Family $5,550 Family
(Combined of deductible and coinsurance)
Preventive Services
Pap Smear Screening – Covered – 100% Covered – subject to deductible and
one per calendar year coinsurance
Mammography Screening Covered – 100% Covered – subject to deductible and
Routine and high-risk mammogram screening coinsurance
in accordance with guidelines established by
the American Cancer Society – one routine
exam per calendar year beginning at age 40
Prostate Specific Antigen (PSA) Covered – 100% Covered – subject to deductible and
Screening coinsurance
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
Early Detection Screening Tests Covered – 100% Not covered
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
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
Hepatitis C (HCV) Screening Covered – 100% Covered – subject to deductible and
When at risk to have signs or symptoms which coinsurance
may indicate a Hepatitis C infection
Well Baby – Six visits up to age 2 Covered – 100% Not covered
Immunizations — age and frequency Covered – 100% Not covered
limitations for selected medically recognized
immunizations (at doctor’s office, pharmacy,
retail clinic)
Bone Marrow Screening Not covered Not covered
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In network Out of network
Physician Office Services
Office Visits - not subject to deductibles or Covered – 50% Not covered
out-of-pocket maximums
Office Consultation & Outpatient Consultation Covered – 50% Not covered
Retail Health Clinic Covered - $50 copayment Not covered
Emergency Medical Care
Hospital Emergency Room Covered – $125 copayment – waived Covered – $125 copayment – waived
Traumatic injury or a life-threatening condition if admitted if admitted
that requires immediate medical attention;
treatment must occur within 72 hours of onset
Physician Covered – 100% Covered – 100%
Qualified Medical Emergency & First Aid Services
Initial examination and treatment of a qualifying
condition resulting from accidental injury or
qualifying medical emergency.
Urgent Care Centers Covered – $50 copayment Not covered
Ground Ambulance — medically necessary Covered – subject to deductible and Covered – subject to deductible and
transport coinsurance coinsurance
Air/Water Ambulance Covered – 100% up to the allowed Covered – 100% up to the allowed
Cover one-way transport from the scene of an amount amount
emergency incident to the nearest available
facility qualified to treat the patient, transporting
a patient one-way or round trip from home to
the nearest available facility qualified to treat the
patient. Medical emergency/accidental injury
patients are provided one-way transportation
from home to the facility. Home bound
patients are provided round trip transportation
from home to the facility and back when
medically necessary and when other means
of transportation could not be used without
endangering the patient’s health.
Medical Emergency/Accidental Injury: Not covered Not covered
Follow-Up Care
Diagnostic Services
Outpatient Magnetic Resonance Imaging Covered – subject to deductible and Covered – subject to deductible and
(MRI), Magnetic Resonance Angiography coinsurance coinsurance
(MRA)
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.
Preauthorization required.
Other Outpatient Diagnostic Tests, Covered – subject to deductible and Covered – subject to deductible and
X-rays, Laboratory & Pathology, PET, CAT coinsurance coinsurance
Scans and Nuclear Medicine
Radiation Therapy — for the diagnosis of Covered – subject to deductible and Covered – subject to deductible and
condition, disease or injury. coinsurance coinsurance
Maternity Services Provided by a Physician
Pre-Natal and Post-Natal Care Covered – subject to deductible and Covered – subject to deductible and
coinsurance coinsurance
Delivery and Nursery Care Covered – subject to deductible and Covered – subject to deductible and
coinsurance coinsurance
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In network Out of network
Maternity Services Provided by a Physician continued
Abortions — must be medically Covered – subject to deductible and Covered – subject to deductible and
necessary coinsurance coinsurance
For medically induced abortion by oral ingestion
of medication when medically necessary
Certified Nurse Midwife Covered – subject to deductible and Covered – subject to deductible and
Obstetrical services by certified nurse coinsurance coinsurance
midwives are limited to basic ante partum
care, normal vaginal deliveries, 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.
The certified nurse midwife must be legally
qualified and registered, certified nurse and/
or licensed, as applicable, to perform these
health care services.
Hospital Care
Semi-Private Room, General Nursing Covered – subject to deductible and Covered for emergency admissions
Services, Meals and Special Diets coinsurance only — subject to deductible and
(Predetermination may be required) coinsurance
Maximum 365 days for each continuous period of hospital confinement or for
successive periods of confinement separated by less than 60 days
Inpatient Medical Care Covered – subject to deductible and Covered – subject to deductible and
coinsurance coinsurance
Chemotherapy Covered – subject to deductible and Covered – subject to deductible and
coinsurance coinsurance
Alternatives to Hospital Care
Ambulatory Surgical Centers Covered – subject to deductible and Not covered
(Facility must satisfy Program requirements coinsurance
and be an approved facility)
Skilled Nursing Facility Covered — subject to deductible and Not covered
(Must be an approved BCBS Skilled Nursing coinsurance
Facility) Limited to 100 days per benefit
period. Renewable after 60 days of
continuous non-confinement.
Hospice Care Covered — subject to deductible and Not covered
(Provider approval required) coinsurance
Limited to 2 days of hospice care for
each remaining inpatient hospital day.
Lifetime maximum of 210 days.
Home Health Care Covered — subject to deductible and Not covered
(Facility approval required) coinsurance
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.
Each visit by member of the home
health care team, and each home
health aide visit is considered the
equivalent of 1 home visit.
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In network Out of network
Outpatient Surgical Services
Surgery — includes materials, supplies, Covered – subject to deductible and Covered – subject to deductible and
preoperative and post operative care, and coinsurance coinsurance
suture removal
Voluntary Sterilization — excludes reversal Covered – subject to deductible and Covered – subject to deductible and
sterilization coinsurance coinsurance
Human Organ Transplants
Specified Organ Transplants Covered – subject to deductible and Covered – subject to deductible and
Contact Human Organ Transplant Program coinsurance coinsurance
Preauthorization required. Must be performed
in a Blue Distinction Center and patient
enrolled in Case Management.
Mental Health Care and Substance Abuse Treatment
Services must be preauthorized by Inpatient: Up to 45 days treatment Inpatient: Not covered unless
ValueOptions (877-228-3912) — not mandatory each for psychiatric and substance medical emergency admission.
for Medicare Enrollees abuse covered — 100% up to the Outpatient:
allowed amount. Mental Health: Up to 35 visits covered
Outpatient: per benefit period — Visits 1-20:
Mental Health: Up to 35 visits covered 100% up to the allowed amount,
per benefit period — Visits 1-20: Visits 21-35: up to 75% of the allowed
100% up to the allowed amount, amount
Visits 21-35: up to 75% of the allowed Substance Abuse: Up to 35 visits
amount per benefit period covered at 100%
Substance Abuse: Up to 35 visits up to the allowed amount
per benefit period covered at 100%
up to the allowed amount
Other Services
Allergy Testing Not covered Not covered
Allergy Therapy/Serum Covered subject to deductible and Covered subject to deductible and
coinsurance coinsurance
Chiropractic Care Covered – subject to deductible and Covered – subject to deductible and
Emergency first aid within 72 hours and coinsurance coinsurance
diagnostic x-ray of the spine only
Excludes adjustment manipulation and initial
office visit
Outpatient Physical, Speech and Covered — subject to deductible and Not covered
Occupational Therapy coinsurance
(medical necessity required) Limited to 60 combined visits per
calendar year, per condition.
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.
* Durable Medical Equipment — When processed as part of inpatient services or office services, subject to deductible and coinsurance.
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In network Out of network
Durable Medical Equipment* Covered — 100% Not covered
Other Services continued
Prosthetic and Orthotic Appliances Covered — 100% Not covered – with the exception of
Hair Pieces and Wigs — Wigs and appropriate wigs
related supplies (standard and tape) are covered
for any age for an individual whov is suffering hair
loss from the effects of chemotherapy, radiation
therapy or other treatments for cancer. The
purchase of wig and related supplies maximum
benefit is $250. Thereafter, the maximum annual
benefit is up to $125
Prosthetic and Orthotic: Jaw Motion Not covered Not covered
Rehabilitation
(Jaw motion rehabilitation system and
related items)
Diabetes Education Covered — 100% Not covered
Covers comprehensive, American Diabetes
Association-approved education classes for
newly-diagnosed or uncontrolled diabetics
Cardiac Rehabilitation – Only Phases I Up to 36 sessions (3 sessions per Not covered
and II are covered week times 12 weeks) covered at
Must begin within 3 months of a cardiac event 100% up to the allowed amount
and be completed within 6 months.
Hearing Care – must be a participating provider
Audiometric exam — once every 36 months 100% up to the allowed amount Not covered
Hearing aid evaluation — once every 36 100% up to the allowed amount Not covered
months
Ordering and fitting the hearing aid (one 100% up to the allowed amount Not covered
monaural) standard or digital — every 36
months
Binaural hearing aids for children 19 and 100% up to the allowed amount Not covered
under — once every 36 months
Hearing aid conformity test — once every 100% up to the allowed amount Not covered
36 months
Vision Care
Routine exam Under the medical coverage, one Under the medical coverage, one
routine vision exam covered with a $25 routine vision exam covered with a $25
copayment, once every 24 months. copayment, once every 24 months.
Prescription Drugs
Coverage administered by Express Scripts 866-662-0274
Retail Tier 1: Generic $12
(30-Day Supply) Tier 2: Preferred Brand $40
Tier 3: Non-preferred Brand $100
Mail Order Tier 1: Generic $24
(90-Day Supply) Tier 2: Preferred Brand $80
Tier 3: Non-preferred Brand $200
This is intended as an easy-to-read guide. It is not a contract. An official description of benefits is contained in
applicable Blue Cross Blue Shield of Michigan coverage documents.
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Definitions
The following definitions apply to the UAW Trust members in the Preferred Provider Organization (PPO).
Monthly Contribution:
The dollar amount a retiree or surviving spouse must pay each month to remain enrolled in UAW Trust coverage.
Deductible:
The amount a member must pay toward covered medical services within a calendar year before the Plan begins paying.
Coinsurance:
The percentage amount a member must pay toward covered medical services, after the deductible is met. The Plan and the
member share the cost of covered medical services until the out-of-pocket maximum is met for the calendar year.
Out-of-Pocket Maximum:
The total dollar amount a member must pay toward covered medical services in any calendar year. The out-of-pocket
maximum includes both the deductible and coinsurance amounts. Once the out-of-pocket maximum is met, all covered
medical services will be paid by the Plan at 100% for the remainder of that calendar year.
Copayment (Copay):
A fixed dollar amount paid by the member for a covered medical service (e.g., office visits, urgent care, etc.).
Participating or In-Network Providers:
Provders (i.e., hospitals and doctors, etc.) that participate with Blue Cross Blue Shield and have signed a formal agreement
with the Plan to accept the allowed amount for a service as payment in full.
Out-of-Network Providers:
Providers (i.e., hospital and doctors, etc.) that do not participate with the Blue Cross Blue Shield established network for the
Plan. Using out-of network providers may result in higher out-of-pocket costs to you for covered medical services.
Non-participating Providers:
Providers (i.e., hospitals and doctors, etc.) that do not participate with Blue Cross Blue Shield and have no signed a formal
agreement with the Plan. Non-participating providers are under no obligation to accept the Blue Cross Blue Shield allowed
amount as payment in full. There is often no coverage for non-emergency care and services provided by non-participating
providers.
Prescription Drug Categories
Tier 1
Generic Medications (Equivalents or Alternatives)
Tier 2
Brand Medications (Single Source, Preferred Brand, and Sensitive Drug Classes)
Tier 3
Brand Medications (Multi-Source or Non-Preferred Brand)
Note: This document is provided for informational purposes and should not be used for legal or medical interpretation
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Explanations and Appeals
After your claims are submitted to BCBS by your providers, you will receive an Explanation of Benefits (EOB) statement. The
EOB provides you with information about claim dates of service, deductibles and coinsurance balances related to the type of
services you and your family received.
You may sign up to obtain your EOB online at bcbsm.com.
Reviewing the Explanation of Benefits can help you track:
• the type of services rendered
• the providers who performed the services
• the deductibles and coinsurance amounts you’ve paid and any remaining balances
• any additional amounts you may owe
In addition to receiving an EOB, you will most likely receive a billing statement from your provider, showing any outstanding
balances you may owe. To confirm you are paying the right amount, compare both statements side-by-side and follow these
steps:
1. Match the service dates and the amounts shown in the grey shaded area entitled “Your Responsibility” on the EOB to
the provider’s billing statement. If they match, pay the provider that amount and file the EOB for your records.
2. If the amounts do not match, or if you have questions, call the customer service number shown on the back of your
BCBS identification card. A BCBS representative will be happy to review the EOB statement and answer your questions.
3. If you are not satisfied with the response or outcome from Customer Service, you may file an appeal with BCBS by
completing an Auto/Inquiry Appeal form. The BCBS Customer Service Representative can help you obtain the form.
4. Once you receive the form, make sure to attach an explanation of your concern and copies of the statements in
question. Check the Appeal Box on the form and mail to:
Auto National Appeal Unit
600 Lafayette East – Mail Code #2004
Detroit, Michigan 48226-2998
5. If the issue remains unresolved, you may file an appeal with the TRUST. Please see your Summary Plan for details.
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Contacts
UAW RETIREE MEDICAL BENEFITS TRUST
Contacts and numbers for Chrysler Retirees and Surviving Spouses
Benefit/Service Contacts Phone Numbers
Blue Cross Blue Shield of Michigan
Hospital, Surgical/Medical Services, Routine Vision – Benefits and claim questions
1-877-832-2829
Mailing Address:
UAW Auto Retiree Service Center
P.O. Box 311088
Detroit, Michigan 48231
Blue Card Access – National Provider Network
1-800-810-2583
(Information on participating network providers at home and while traveling)
Case Management 1-800-845-5982
Precertification Hospital Inpatient (Non-Medicare enrollees only) 1-877-871-3086
Retiree Health Care Connect The UAW Trust eligibility and call center
1-866-637-7555
(Eligibility, membership, address changes, ID card requests, etc.)
Other Benefits/Service Contacts Phone Numbers
Express Scripts (formerly Medco Health)
1-866-662-0274
Prescription Drugs – Mail Order and Retail (Drug Stores)
ValueOptions – Help Line
Precertification – Mental Health and Substance Abuse (required for non-Medicare 1-877-228-3912
members only)
Durable Medical Equipment (DME) and Prosthetics & Orthotics (P&O) 1-888-722-0322
Mail Order Diabetic & Ostomy Suppliers
“Quit the Nic” Smoking Cessation 1-800-775-2583
Websites
Medicare
1-800-633-4227
www.medicare.gov
Veterans Health Administration
1-877-222-8387
www.va.gov/health
UAW Retiree Medical Benefits Trust
www.uawtrust.org
National Internet Site
www.bcbs.com/healthtravel/finder.htm
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R028260 Chrysler PPO
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