USA Health & Dental Plan
Standard Plan
Effective January 1, 2015
STANDARD PLAN APPLIES TO EMPLOYEES OF THE
UNIVERSITY OF SOUTH ALABAMA AND USA HEALTHCARE MANAGEMENT, LLC
EMPLOYED ON OR AFTER JANUARY 1, 2013
Health Care Reform & the USA Health & Dental Plan
The Patient Protection & Affordable Care Act, also known as the Affordable Care Act, was signed into law in 2010. This
Member Handbook update will refer to the Act as the ACA. The law puts in place comprehensive health insurance reforms,
some that have been implemented over the past three years and others which will continue to be implemented in the future.
It is the University’s intent to continue to comply with all aspects of this law. The USA Health & Dental Plan complies with all
eligibility rules and provides all benefits required by the ACA including:
1.
The Plan provides “minimum essential coverage” as required by the ACA. This means the Plan provides the type of
coverage employees need in order to satisfy the individual responsibility requirement under the ACA.
2.
The Plan meets the “minimum value” standard established by the ACA. This means that the Plan’s share of the total
allowed benefit costs covered by the Plan is no less than 60% of such costs.
3.
The Plan’s employee cost-sharing rates are intended to meet the “affordable” standard under the ACA. This means that
the employee cost for single coverage under the Plans is intended to be no more than 9.5% of the employee’s
household income.
The above information means that while there is a new way to shop for health insurance on the Marketplace, you most likely will
not be eligible to receive the premium tax subsidy (lowers the cost of premiums for coverage purchased through the
Marketplace), because the health insurance offered by your employer meets the ACA requirements listed above. However, you
should feel free to shop on the Marketplace and doing so will not affect your employer-sponsored health insurance. You can
access the Health Insurance Marketplace at: www.healthcare.gov or by calling: 1-800-318-2596.
Standard Plan - 1
USA Health & Dental Plan – STANDARD PLAN
SUMMARY OF IMPORTANT PROVISIONS
STANDARD PLAN ELIGIBILITY
The Standard Plan applies to employees of the University of South Alabama and USA HealthCare Management, LLC,
employed on or after January 1, 2013. Employees who are in a benefits eligible position based on the USA Health &
Dental Plan Eligibility Policy are offered this coverage and may elect to cover eligible dependents. The employee must
enroll individuals to be covered and maintain an accurate listing of eligible dependents. The employee must also elect
single or family coverage with the required monthly cost sharing amount.
Effective January 1, 2015, the USA Health & Dental Plan Eligibility Policy is intended to comply with the Affordable Care
Act which requires an offer of coverage to all employees credited with 30 hours of service per week or 130 hours of
service per month on average. Coverage may start the later of the first of the month following the employee’s start date
or the date the application for coverage is received by the Human Resources Department.
The USA Health & Dental Plan determines hours of service based on the employer records and may defer the offer of
coverage if the employee is determined to be “seasonal” or having “variable hours” in which case benefits eligible status
will be determined using a 12-month measurement period for a 12-month stability period in compliance with the
Affordable Care Act.
BASE PLAN ELIGIBILITY
Indiviuals employed prior to January 1, 2013 are eligible for the Base Plan described in a separate notification.
NON-GRANDFATHERED STATUS UNDER THE AFFORDABLE CARE ACT (ACA)
The Standard Plan is not a “Grandfathered Plan” under the Affordable Care Act and complies with all requirements of
the Act, including but not limited to, coverage of preventative health services without any cost-sharing, cost-sharing rules
for out-of-network emergency services, limitations on cost-sharing, and coverage requirements for clinical trials.
All co-pays, deductibles, and coinsurance apply to the out-of-pocket maximum (excluding Cyberknife treatment, bariatric
services, adult vision up to age 19, skilled nursing facilities and prescription drugs). For members up to age 19,
deductibles and coinsurance for in-network dental services also apply to the out-of-pocket maximum.
FEDERAL LAWS & ACTS
Not all federal laws and acts apply to non-federal governmental plans by election. This is true for mental health and
substance use benefits. You should always check your recommended treatment with Blue Cross Blue Shield to be sure
of the benefits available.
ADDITIONAL INFORMATION
For questions concerning eligibility and enrollment, Change-In-Status Events, assistance in making Application for
coverage contact:
HUMAN RESOURCES DEPARTMENTS
University of South Alabama Campus ....................460-6133
USA Medical Center................................................471-7325
USA Children’s and Women’s Hospital...................415-1604
Website ............... www.southalabama.edu/humanresources
USA HEALTH SYSTEM
Help Line .................................................................460-7862
Website. ..................................... www.usahealthsystem.com
Physician Directory ................................................................
www.usahealthsystem.com/physiciandirectory
Standard Plan - 2
USA HEALTH & DENTAL PLAN – STANDARD PLAN – BENEFIT SUMMARY
TYPES OF PROVIDERS & BENEFIT DIFFERENCES
IN-NETWORK: Includes all USA Health Network hospitals, physicians and clinics. USA Health Network providers have
the highest benefit level. When you use a USA Health Network provider you will pay less. Also included are “Other
PPO” providers. Other PPO providers includes facilities, physicians and providers which are under contract with BCBS
but are not USA Health Network providers which have a slightly higher cost to you.
OUT-OF-NETWORK: Also referred to as Non-PPO Providers, have the lowest benefit and cost you the most.
ALLOWED AMOUNT OR ALLOWANCE: Benefit payments are based on the amount of the provider’s charge that BCBS
recognizes for payment of benefits. The “allowed amount” or “allowance” may vary depending whether you use an InNetwork or Out-of-Network provider and where services are received. You are responsible for the provider’s charges
over the allowed amount or allowance when you receive services Out-of-Network.
INPATIENT HOSPITAL FACILITY SERVICES
BENEFIT
Inpatient Facility Coverage
(Including Maternity)
Coverage for semi-private
room and board, intensive care
units, general nursing services
and usual hospital ancillaries.
Preadmission Certification
IN-NETWORK
OUT-OF-NETWORK
USA Health Network: Covered at 100% of the
allowance with no deductible or copay.
Out-of-Network coverage available only for
medical emergencies or accidental injuries.
Other PPO: Covered at 100% of the allowance
after $750 per admission deductible and $100
copay days 2-5.
Non-PPO Provider Outside Alabama:
Non-PPO Provider In Alabama:
Covered at 100% of the allowance after $750
per admission deductible and $100 copay days
2-5 only for medical emergency or accidental
injury; otherwise, not covered.
All hospital admissions require preadmission certification, except maternity. Emergency admissions
require certification within 48 hours of admission: call 1-800-248-2342 (toll-free). If preadmission
certification is not obtained, there will be a $400 penalty imposed on benefits.
Note: In Alabama, inpatient hospital benefits are paid only if received from a BCBS provider. Outside Alabama inpatient hospital
benefits are paid only if received from a BlueCard PPO provider, except in cases of medical emergency or accidental injury.
OUTPATIENT HOSPITAL FACILITY SERVICES
BENEFIT
Surgery
IN-NETWORK
USA Health Network: Covered at 100% of the
allowance. No facility copay.
Other PPO: Covered at 100% of the allowance
after a $250 facility copay.
CyberKnife Treatment
Note: CyberKnife services
covered only at the Mitchell
Cancer Center.
Medical Emergency
Note: Use of an Emergency Room
for treatment that is not a medical
emergency or injury as determined
by the claims administrator will be
paid according to the major
medical benefits schedule at 80%
of the allowance after the $400
calendar year deductible.
Standard Plan - 3
USA Mitchell Cancer Center: Covered at 100%
of the allowance. No facility copay.
OUT-OF-NETWORK
Non-PPO Provider Outside Alabama: Not
covered unless due to medical emergency or
accidental injury.
Non-PPO Provider In Alabama: Not covered.
Not covered.
Other PPO: Not covered.
USA Health Network: Covered at 100% of the
allowance after a $25 facility copay. *
Other PPO: Covered at 100% of the allowance
after a $250 facility copay. *
* Copay waived if admitted within 24 hours.
Non-PPO Provider Outside Alabama:
Covered at 100% of the allowance after a $250
facility copay.
Non-PPO Provider In Alabama: Same benefit
but limited to only medical emergency;
otherwise, not covered.
Accidental Injury
USA Health Network: Covered at 100% of the
allowance with no deductible or copay .
Other PPO: Covered at 100% of the allowance
with no deductible or copay.
Non-PPO Provider Outside Alabama:
Covered at 100% of the allowance with no
deductible or copay within 72 hours of the
accident. Thereafter, covered at 80% of the
allowance, after the calendar year deductible. *
Non-PPO Provider In Alabama: Same benefit
but limited only for treatment of the accidental
injury; otherwise, not covered. *
* After initial 72 hours covered at 80% after the
calendar year deductible.
Diagnostic X-ray
Diagnostic Lab and
Pathology
Hemodialysis, IV Therapy
Chemotherapy and
Radiation Therapy
USA Health Network: Covered at 100% of the
allowance. No facility copay.
Non-PPO Provider Outside Alabama:
Other PPO: Covered at 100% of the allowance
after a $50 facility copay.
Covered at 100% of the allowance after a $50
facility copay only for medical emergency or
accidental injury; otherwise, not covered.
USA Health Network: Covered at 100% of the
allowance. No facility copay.
Non-PPO Provider Outside Alabama:
Other PPO: Covered at 100% of the allowance.
No facility copay.
Covered at 100% of the allowance for medical
emergency or accidental injury; otherwise, not
covered.
USA Health Network: Covered at 100% of the
allowance with no facility copay.
Not covered.
Non-PPO Provider In Alabama:
Non-PPO Provider In Alabama:
Other PPO: Covered at 100% of the allowance
after a $25 facility copay.
Note: In Alabama, outpatient benefits for Non-PPO hospitals are available only in cases of medical emergency or accidental injury.
PHYSICIAN SERVICES
BENEFIT
Office Visits and
Outpatient
Consultations
Emergency Room
Physician
IN-NETWORK
USA Health Network: Covered at 100% of the
allowance after a $10 office visit copay.
Other PPO: Covered at 100% of the allowance after a
$35 office visit copay.
USA Health Network: Covered at 100% of the
allowance after a $10 office visit copay.
Other PPO Covered at 100% of the allowance after a
$35 office visit copay.
Surgery &
Anesthesia
USA Health Network: Covered at 100% of the
allowance.
Other PPO: Covered at 100% of the allowance.
OUT-OF-NETWORK
Non-PPO Provider Outside Alabama:
Covered at 80% of the allowance, after the
calendar year deductible.
Non-PPO Provider In Alabama: Covered
same as in-network Other PPO Physician only
for medical emergency or accidental injury;
otherwise, not covered.
Non-PPO Provider Outside Alabama:
Covered at 100% of the allowance, after a $35
office visit copay.
Non-PPO Provider In Alabama: Covered
same as in-network Other PPO but only for
medical emergency or accidental injury;
otherwise, not covered.
Non-PPO Provider Outside Alabama:
Covered at 80% of the allowance, after the
calendar year deductible.
Non-PPO Provider In Alabama: Covered
same as in-network Other PPO Physician but
only for medical emergency or accidental injury;
otherwise, not covered.
Bariatric Surgery
(Surgeon, Assistant
Surgeon & Anesthesia)
Limited to 1 procedure
per member per lifetime.
Standard Plan - 4
USA Health Network: Covered at 100% of the
allowance.
Other PPO: Covered at 100% of the allowance.
Note: Bariatric Services in Alabama must be performed
by a BCBS Bariatric Surgery Network Provider.
Not covered
Second Surgical
Opinions
USA Health Network: Covered at 100% of the
allowance.
Not covered.
Other PPO: Covered at 100% of the allowance.
Inpatient Visits and
Inpatient
Consultations
USA Health Network: Covered at 100% of the
allowance.
Non-PPO Provider Outside Alabama:
Covered at 80% of the allowance, after the
calendar year deductible.
Other PPO: Covered at 100% of the allowance.
Non-PPO Provider In Alabama: Covered
same as in-network Other PPO Physician but
only for medical emergency or accidental injury;
otherwise, not covered.
Maternity
USA Health Network: Covered at 100% of the
allowance.
Non-PPO Provider Outside Alabama:
Covered at 80% of the allowance, after the
calendar year deductible.
Other PPO: Covered at 100% of the allowance.
Non-PPO Provider In Alabama: Covered
same as in-network Other PPO Physician but
only for medical emergency or accidental injury;
otherwise, not covered.
Diagnostic X-rays
USA Health Network: Covered at 100% of the
allowance.
Non-PPO Provider Outside Alabama:
Covered at 80% of the allowance, after the
calendar year deductible.
Other PPO: Covered at 100% of the allowance.
Non-PPO Provider In Alabama: Covered
same as in-network Other PPO Physician but
only for medical emergency or accidental injury;
otherwise, not covered.
Diagnostic Lab
Exams
USA Health Network: Covered at 100% of the
allowance.
Non-PPO Provider Outside Alabama:
Covered at 80% of the allowance, after the
calendar year deductible.
Other PPO: Covered at 100% of the allowance.
Non-PPO Provider In Alabama: Covered
same as in-network Other PPO Physician but
only for medical emergency or accidental injury;
otherwise, not covered.
TMJ Phase I
Treatment
USA Health Network: Covered at 100% of the
allowance after a $10 office visit copay.
Other PPO Covered at 100% of the allowance after a
$35 office visit copay.
Non-PPO Provider Outside Alabama:
Covered at 100% of the allowance after a $35
office visit copay.
Non-PPO Provider In Alabama: Not covered.
Note: In Alabama, physician benefits for non-member hospitals are available only in cases of medical emergency or accidental injury.
PRESCRIPTION DRUGS
Prescription Drug Card:
Participating Pharmacy:
Non-Participating Pharmacy:
Maintenance Prescriptions
up to a 90 day supply; one
copay for each 30 day supply
Separate $100 prescription drug deductible per member per
calendar year; maximum of 3 per family. Each prescription
purchased from a Participating Pharmacy will be covered at
100% after the deductible with the following copays:
No benefits are available for
prescriptions purchased in a nonParticipating Pharmacy in the state
of Alabama.
TYPE:
Standard Plan - 5
COPAY PER 30 DAY SUPPLY:
Generic
$
10.00
Preferred Brand Name
$
50.00
Non-Preferred Brand Name
$
75.00
Specialty
50% to annual out-of-pocket
limit of $5,000.
Contraceptives
100%, no copay, for all FDA
approved contraceptive
methods prescribed by a
physician.
Prescription drugs purchased from a
non-participating pharmacy out of
state or out of the country will
process at the participating
pharmacy allowance plus the
applicable copayment. The member
is responsible for any cost over the
particpating pharmacy allowance
plus the applicable copayment.
Prescription Drugs Continued – Diabetic Supplies

Diabetic supplies are covered through the Drug Card Program.

Diabetic supplies purchased on the same day as insulin will be provided without an additional copay. The only copay that will
apply is the copay for the insulin.

Diabetic testing supplies including blood glucose test strips, lancets, and meters are avilable ONLY through the pharmacy benefit,
not subject to any deductible or copay; only claims for supplies submitted electronically by a Particpating Pharmacy are covered.
There are no benefits for this in Major Medical (home health/DME). Injectable and oral diabetic medications will require a copay,
and ARE subject to the deductible.
MAJOR MEDICAL BENEFITS
Most of the significant medical services are paid at 100% with or without a copay or deductible. Other covered services are subject to
a calendar year deductible and then the Plan pays 80% of the allowed amount up to the annual out-of-pocket limit. The out-of-pocket
maxlimum is intended to help the participant with major expenses. Copays, deductibles, and coinsurance apply to the out-of-pocket
maximum (excluding Cyberknife treatment, bariatric services, vision services up to age 19, skilled nursing facilities, and prescription
drugs). The deductibles and coinsurance for in-network dental services under the dental benefits apply to the out-of-pocket maximum
for members up to age 19.
Calendar Year Deductible
$400 per member each calendar year; no family maximum.
Annual Out-of-Pocket
Maximum
$1,200 per individual plus the $400 calendar year deductible
for a total of $1,600; complies with the Affordable Care Act
family maximum of $12,700.
There is no out-of-pocket maximum.
OTHER COVERED SERVICES
BENEFIT
Chiropractor Services
IN-NETWORK
Covered at 80% of the allowance, after the
calendar year deductible.
OUT-OF-NETWORK
Non-PPO Provider Outside Alabama:
Covered at 80% of the allowance, after the
calendar year deductible.
Non-PPO Provider In Alabama: Not covered.
Speech Therapy
Limited to 60 visits per member
each calendar year
USA Health Network: Covered at 100% of the
allowance, after the $10 office visit copay if
applicable.
Covered at 80% of the allowance, after the
calendar year deductible.
Other PPO: Covered at 80% of the allowance,
after the calendar year deductible.
Occupational Therapy
Limited to 60 visits per member
each calendar year
USA Health Network: Covered at 100% of the
allowance, after the $10 office visit copay if
applicable.
Covered at 80% of the allowance, after the
calendar year deductible.
Other PPO: Covered at 80% of the allowance,
after the calendar year deductible.
Physical Therapy
Limited to 60 visits per member
each calendar year
USA Health Network: Covered at 100% of the
allowance, after the $10 office visit copay if
applicable.
Covered at 80% of the allowance, after the
calendar year deductible.
Other PPO: Covered at 80% of the allowance,
after the calendar year deductible.
Durable Medical Equipment
Covered at 100% of the allowance, no
deductible.
Not covered.
Covered at 100% of the allowance with no
deductible for services rendered by a
Participating Home Health Agency in Alabama.
Not covered.
Covered at 100% of the allowance with no
deductible.
Not covered.
Limited to 180 days lifetime max
Ambulance Services
Covered at 80% of the allowance, after the calendar year deductible.
Orthotic devices are limited to a
maximum benefit of two pair every
12 consecutive months
Home Health
Requires Precertification
Hospice
Standard Plan - 6
Allergy Testing
USA Health Network: Covered at 100% of the
allowance, after a $10 copay.
Not covered.
Other PPO: Covered at 80% of the allowance,
after the calendar year deductible.
Allergy Treatment
Covered at 80% of the allowance, after the
calendar year deductible.
Tobacco Quitline
A tobacco cessation program for employees and spouses provides support through telephonebased counseling and nicotine replacement therapy. Call 1-888-768-7848 for information.
Not covered.
PREVENTIVE CARE SERVICES
BENEFIT
IN-NETWORK
OUT-OF-NETWORK
The Standard Plan complies with the ACA by providing benefits for preventive care services at 100%, with no deductible or copay, but
only when received by a USA Health System Provider. The following is a portion of the immunizations and preventive services
available for adults, women, and children. Go to www.bcbsal.com/preventiveservices for a complete listing of these benefits.
Well Child Care
Includes 9 visits during the first two
years of the child’s life and one
visit each year thereafter
Routine Developmental
Screening
Three exams between 9 months
and 30 months of life
Routine Office Visit
Limited to one visit every year
Routine Immunizations
USA Health Network: Covered at 100% of the allowance, no
deductible or copay.
Other PPO: Covered at 100% of the allowance after a $35 office
visit copay.
Not covered.
USA Health Network: Covered at 100% of the allowance, no
deductible or copay.
Other PPO: Covered at 100% of the allowance after a $35 office
visit copay if charged.
Not covered
USA Health Network: Covered at 100% of the allowance, no
deductible or copay.
Other PPO: Covered at 100% of the allowance after a $35 office
visit copay.
Not covered.
Covered at 100% of the allowance no deductible or copay.
Not covered.
USA Health Network: Covered at 100% of the allowance, no
deductible or copay.
Other PPO: Covered at 100% of the allowance after the $35 copay
if charged.
Not covered.
USA Health Network: Covered at 100% of the allowance, no
deductible or copay.
Other PPO: Covered at 100% of the allowance after the $30 copay
if charged.
Not covered.
USA Health Network: Covered at 100% of the allowance, no
deductible or copay.
Other PPO: Covered at 100% of the allowance after the $35 copay
if charged.
Not covered.
USA Health Network: Covered at 100% of the allowance, no
deductible or copay.
Other PPO: Covered at 100% of the allowance after the $35 copay
if charged.
Not covered.
USA Health Network: Covered at 100% of the allowance, no
deductible or copay; includes associated office visit.
Other PPO: Covered at 100% of the allowance including the
associated office visit after the $35 copay.
Not covered.
www.bcbsal.com/immunizations
Cervicle Cancer Screening
(Pap Smear)
Limited to one per year
Human Papillomavirus (HPV)
Screening
One screening every three years
for females age 30 and older
Breast Cancer Screening Mammograms
One base-line for females ages
35-39; females age 40 and older,
limit one per calendar year
Prostate Screening
Males age 40 and over, limit one
Prostate Specific Antigen (PSA)
each year
Routine Colorectal Cancer
Screening – Age 50 and over
Hemocult stool check and Fecal
occult blood test once each year
Sigmoidoscopy every three years
Double-contrast barium enema
every 5 years
Colonoscopy every 10 years
Standard Plan - 7
(outpatient hospital services may require a copay)
Cholesterol Screening
USA Health Network: Covered at 100% of the allowance, no
deductible or copay.
Other PPO: Covered at 100% of the allowance after the $35 copay
if charged.
Not covered.
USA Health Network: Covered at 100% of the allowance, no
deductible or copay.
Other PPO: Covered at 100% of the allowance after the $35 copay
if charged.
Not covered.
Limit one every two years for ages
65 and older and ages 65 and
younger if at risk
Vision Screening
Covered at 100% of the allowance after a $35 office visit copay.
Not covered.
Limit one every five years for
females age 45 and older and
males age 35 and older
Osteoperosis Screening
Routine
MENTAL HEALTH AND SUBSTANCE USE DISORDER
BENEFIT
Inpatient Facility Services
Limited to 60 days in a lifetime
IN-NETWORK
OUT-OF-NETWORK
Covered at 80% of the allowance after the Major
Medical deductible. Covers up to 30 days per
member each calendar year.
Covered at 80% of the allowance after the Major
Medical deductible. Covers up to 30 days per
member each calendar year.
Out-of-Network coverage available only for
medical emergencies or accidental injuries.
Inpatient Physician Services
Limited to 60 days in a lifetime
Covered at 80% of the allowance after the
calendar year deductible. Covers up to 30 days
per member each calendar year.
Covered at 80% of the allowance after the
calendar year deductible. Covers up to 30 days
per member each calendar year.
Out-of-Network coverage available only for
medical emergencies or accidental injuries.
Mental Health Outpatient
Physician Services
USA Health Network: Covered at 100% of the allowance after $10 office visit copay.
Other PPO or Non-PPO: Covered at 100% of the allowance after the $25 office visit copay.
Limited to 60 visits per member each year combined with Substance Use Disorder Outpatient Physician
Services
Substance Use Disorder
Outpatient Physician
Covered at 80% of the allowance after the calendar year deductible.
Limited to 60 visits per member each calendar year combined with Mental Health Outpatient Physician Services
The USA Health & Dental Plan as a non-federal governmental plan elects out of the Mental Health Parity and Substanc e Use Act and
does not provide parity of benefits. You should coordinate your mental health and substance abuse treatment with your physician and
the claims administrator to ensure that you have coverage.
SPECIAL PATIENT ADVOCATE PROGRAMS
Individual Case Management
A program to assist members in coordinating care in the event of a lengthy illness.
Disease Management
A program for chronic conditions such as asthma, diabetes, coronary artery disease, congestive
heart failure and chronic obstructive pulmonary disease. For more information, please call 1-888841-5741.
Baby Yourself
Prenatal wellness program; For more information, call 1-800-222-4379. You can also enroll online at
www.behealthy.com.
Please note: Providers/Specialists may be listed in the PPO directory, but not covered as PPO benefits by this group health plan (i.e. DME,
Ambulance, Midwives, Allergists). Some of these benefits may be covered under Other Covered Services or not at all. Please check your benefit table
or benefit booklet to determine coverage. All non-participating hospitals will not be covered.
Group 78380 (University of South Alabama) and 79873 (USA HealthCare Management LLC)
Standard Plan - 8
USA Health & Dental Plan – Dental Plan – Benefit Summary
DENTAL BENEFIT
STANDARD PLAN – Non-Grandfathered Status
DENTAL BENEFIT PREFERRED PROVIDER NETWORK
The USA Health & Dental Plan offers dental benefits using a Preferred Provider Network of dental providers who contract with
Blue Cross Blue Shield of Alabama (BCBS). The Dental Network is a statewide network. This managed care program is
designed to promote quality and cost effective dental care.
Network dentists will file all claims and accept the BCBS allowed amount or allowance as payment in full (after any deductible
and coinsurance you are required to pay). Payments for covered services provided by in-network dentists in Alabama are based
on the dental network fee schedule (allowed amount or allowance) which establishes the maximum amount to be paid for
services rendered by an Out-of-Network dentist.
Payments for covered services provided by Out-of-Network dentists in Alabama will be made according to the dental network fee
schedule at the same level as In-Network services. However, you may be responsible for the difference between the BCBS
allowance and the dentist’s charge (plus any deductible and coinsurance). You may also have to file the claim if your dentist’s
office will not do so. Payments for covered services received outside Alabama will be paid at the lesser of the amount BCBS will
recognize as the “allowed amount” or the amount charged by the dentist.
GENERAL PROVISIONS
Deductible
$25 per member each calendar year.
Benefit Maximum
No maximum for members up to age 19.
$1,000 per member age 19 and over each calendar year.
Annual Out-of-Pocket
Maximum
The deductibles and coinsurance for members up to age 19 will apply to the annual health
In-network out-of-pocket maximum (Major Medical).
DIAGNOSTIC AND PREVENTIVE (Exams and Cleanings)
Covered at 100%, with no deductible , includes:

Dental exams up to twice per calendar year.

Full mouth x-rays, one set during any 36 consecutive months.

Bitewing x-rays, up to twice per calendar year.

Other dental x-rays, used to diagnose a specific condition.

Routine cleanings, twice per calendar year.

Tooth sealants on teeth numbers 3, 14, 19, and 30, limited to one application per tooth each 48 months. Benefits are
limited to a maximum payment of $20 per tooth. Limited to the first permanent molars of children through age 13.

Fluoride treatment for children through age 18 twice per calendar year.

Space maintainers (not made of precious metals) that replace prematurely lost teeth for children through age 18.
RESTORATIVE (Fillings and Root Canals)
Covered at 80%, after the deductible. Includes:

Fillings made of silver amalgam and synthetic tooth color materials.

Simple tooth extractions.

Direct pulp capping, removal of pulp and root canal treatment.

Repairs to removable dentures.

Emergency treatment for pain.
SUPPLEMENTAL (Oral Surgery and Anesthesia)
Covered at 80%, after the deductible, includes:

Oral surgery for tooth extractions and impacted erupted wisdom teeth.

General anesthesia given for oral or dental surgery. This means drugs injected or inhaled for relaxation or to lessen pain,
or to make unconscious, but not analgesics: drugs given by local infiltration, or nitrous oxide.

Treatment of the root tip of the tooth including its removal.
Standard Plan - 9
PROSTHETIC (Crowns and Dentures)
Covered at 50%, after the deductible, includes:

Full or partial dentures.

Fixed or removable bridges.

Inlays, onlays, or crowns to restore diseased or accidentally broken teeth, if less expensive fillings are not adequate.
PERIODONTIC (Gum Disease)
Covered at 50%, after the deductible , includes:

Periodontic exams twice each 12 months.

Removal of diseased gum tissue and reconstructing gums.

Removal of diseased bone.

Reconstruction of gums and mucous membranes by surgery.

Removing plaque and calculus below the gum line for periodontal disease.
Payments are based on the “Allowed Amount.” Benefits are subject to the terms, limitations and conditions of the group contract.
USA HEALTH & DENTAL PLAN
The USA Health & Dental Plan is designed to assist members with the high cost of medical care and provide
preventive health services. The University of South Alabama contracts with Blue Cross Blue Shield of
Alabama (BCBS) as the claims administrator. BCBS is responsible for the day to day operation of the Plan,
paying claims, maintaining the Preferred Provider Organization (PPO), making determinations concerning
medical necessity, medically necessary, the allowance amount for all services, and managing all aspects of
the health and dental benefits.
If you have any problems with the Plan or need additional information you should contact:
BLUE CROSS AND BLUE SHIELD OF ALABAMA
450 RIVERCHASE PARKWAY EAST
P.O. BOX 995
BIRMINGHAM, AL 35298-0001
Customer Service ..............................................................1-877-345-6171
Website............................................................................ www.bcbsal.com
Preadmission Certification...................... (205) 988-2245 or 800-248-2342
BlueCard PPO ....................................................................(800) 810-2583
BlueCard PPO Website ........................................ www.provider.bcbs.com
Group Number 13515 (USA) and 86113 (HCM)
General information and further assistance can be obtained by contacting:
HUMAN RESOURCES DEPARTMENTS
University of South Alabama Campus ....................460-6133
USA Medical Center ...............................................471-7325
USA Children’s and Women’s Hospital ..................415-1604
Website ............... www.southalabama.edu/humanresources
USA HEALTH SYSTEM
Help Line.................................................................460-7862
Website. ..................................... www.usahealthsystem.com
Physician Directory ................................................................
www.usahealthsystem.com/physiciandirectory
Standard Plan - 10