The amounts in the chart below are for in-network services only. If you go out of network, your amounts will be different.
(1) Your payments to MDLIVE do not count toward the in-network deductible and out-of-pocket maximums for the HSA and PPO medical plans.
(2) The plan covers bariatric surgery, knee and hip replacements, select spine surgeries and some transplants if performed at a Blue Distinction Center.
(3) Certain high-tech radiology tests (CT scans and MRIs) require prior authorization except during a medical emergency. Authorization is not required for low resolution diagnostic services, including mammograms, sonograms, and x-rays.
(4) Your newborn is automatically covered under the plan for the first 31 days after the date of birth. If you wish to continue coverage for the newborn beyond that date, you must add the child to your medical coverage through the My BMC Compensation & Benefits website (select the Life Changes tab) within 31 days after the newborn’s date of birth.
(5) Other preventive exams and cancer screenings may have age and time limit restrictions.
(6) Additional plan authorization review required after 30 days.
Important: Other limitations may apply. If you have questions about the PPO or HSA medical plans or need more information, take a look at the plan documents on the My BMC Compensation & Benefits website (click on the Plan Documents tile.)