Benefits Summary Special Care

Special CareSM

Single adults and families
Monthly cost $156.15/one adult; $222.30/one adult & child(ren);
$312.20/two adults; $378.50/two adults & child(ren)
Type of coverage Traditional Blue Cross & Blue Shield
limited benefit plan
Eligibility Family size and income
(income review will be waived for individuals transferring from adultBasic by May 2, 2011)
Wait period before becoming eligible None
Pre-existing condition rule

Yes
Coverage excluded for one year for medical condition for which medical advice or treatment was received during the 12 months prior to the effective date of the policy.
(unless transferring from another Blue plan within 30 days or for individuals transferring from adultBasic by May 2, 2011)

Copays 4 doctor office visits/year at $15 PCP copay/$25 specialist copay
Benefits
Doctor office visits 4 visits/year at $15 PCP copay/$25 specialist copay
Hospitalization limited to 21 days per benefit period
Surgery and anesthesia covered
Emergency care $50 copayment (waived if admitted)
Diagnostic services covered
Chemotherapy and radiation therapy covered
Maternity care covered
Newborn care covered for up to 31 days following birth
Dental not covered
Vision and hearing not covered
Prescription drugs not covered
Durable medical equipment not covered
Mental health not covered
Serious mental illness not covered
Substance abuse not covered

For specific information regarding benefits, limitations, and exclusions, please call 1-866-282-2702.