X hits on this document

29 views

0 shares

0 downloads

0 comments

2 / 10

TABLE OF CONTENTS

Introduction

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Coverage Term . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Eligibility

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2-3

Cost of Insurance

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Health Center Referral

..................................

4

Dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Premium Refund Policy

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Termination of Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Extension of Benefits

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Other Coverage Options

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Enrollment Period .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Excess Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Definitions

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-7

Devon Health Services Network

..........................

8

Valley Preferred Network

................................

8

Plan Summary

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Outpatient Prescription Drugs

. . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Covered Medical Expenses

...........................

10-13

Exclusions . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-15

Claim Procedure

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-16

Reimbursement and Subrogation . . . . . . . . . . . . . . . . . . . . . . . . .16

Appeals

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Important Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Under HIPAA's Privacy Rule We are required to provide you with notice of our legal duties and privacy practices with respect to personal health information. You should receive a copy of this notice with your insurance identification card. If, at anytime, you wish to request a copy of the Privacy Notice, write to BCS Insurance Company at: 2 Mid America Plaza, Suite 200, Oakbrook Terrace, Illinois 60181, Attn: HIPPA Privacy Officer or call 630-472-7752.

1

Document info
Document views29
Page views29
Page last viewedWed Dec 07 17:05:03 UTC 2016
Pages10
Paragraphs327
Words15163

Comments