| Notes |
*Plan payment is based on
the allowed amount when you use a participating
provider. You are responsible for charges
greater than the allowed amount when you use a
non-participating Blue Cross provider.
Coverage for substance
abuse is included in the contract. You may
choose to delete substance abuse coverage. Your
premium will be slightly reduced if you delete
substance abuse coverage. Dependents may not be
added to this plan, but they can apply for their
own Simply Blue plan.
This is only a summary, your contract will provide
a detailed description of what is and is not
covered. Services not covered include childbirth
labor and delivery, private-duty nursing,
custodial care or rest cures, eyewear, dental
services, hearing aids, services that are
experimental, not medically necessary or
received while on military duty.
Pre-existing condition you
had during the six months before your enrollment
date are not covered. This limit applies for 12
months. Prior continuous coverage without a gap
in coverage greater than 63 days counts toward
reducing the 12-month period.
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