CurrentBlue Cross Blue Shield - MississippiPolicy N/A

Blue Health Savings Certificate of Coverage (Schedule of Benefits)

Governs the benefit structure, cost-sharing, network rules, and coverage limitations for members enrolled in the Blue Health Savings plan offered by Blue Cross Blue Shield - Mississippi. Affects enrolled subscribers and their dependents, providers, and network participation rules.

Policy Summary

PayerBlue Cross Blue Shield - Mississippi

PolicyBlue Health Savings Certificate of Coverage (Schedule of Benefits)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization for specialty services and certain prescription drugs before benefits will be provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$5,000Individual Network Deductible

$10,000Individual Non-Network Deductible

$14,000Family Network Out-of-Pocket

90%Specialty Ambulatory Coinsurance

80%Typical Network Coinsurance

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Typical Non-Network Coinsurance

Coverage Criteria and Limitations

Coverage criteria and limitations

Coverage is tiered by network status, service type, and program participation; many services require Network Providers, Prior Authorization, or participation in designated programs to receive higher benefit levels.

ALL of the following

ALL of the following
- Network individual deductible: $5,000 (as stated in Schedule of Benefits)
- Non-Network individual deductible: $10,000 (as stated in Schedule of Benefits)
- Family Network out-of-pocket: $14,000 combined (as stated in Schedule of Benefits)
All Covered Services are subject to Care Management; benefits are based on Allowable minus applicable deductible, copayment, and/or coinsurance

ALL of the following

HealthyYou/Blue Primary Care Network preventive services: 100% (Deductible waived) when rendered by designated Network Providers; Non-Network: Not Covered

ALL of the following

All Specialty Services are subject to Medical Policy (including Medical Necessity) and a determination by the Company of the most clinically appropriate setting
Specialty Services only covered at higher benefit level when provided by a Center of Excellence or Blue Specialty Network Provider; No Benefits without Pre-Certification or Prior Authorization
Ambulatory specialty services coinsurance: Center/Blue Specialty Network = 90%; Non-Blue Specialty Network = 70%; Non-Network = Not Covered
Inpatient specialty services coinsurance: Center of Excellence = 90%; Non-Center of Excellence Network = 70%; Non-Network = Not Covered

ALL of the following

General inpatient hospital services coinsurance: Network = 80%; Non-Network = 60%
Outpatient hospital and other non-specialty services coinsurance: Network = 80%; Non-Network = 60%
Inpatient rehabilitation limited to 30 inpatient days per Calendar Year when provided by Network Provider; Non-Network rehabilitation not covered

ALL of the following

Physical medicine and related therapy visit limits: 20 visits per Calendar Year (as stated in Schedule of Benefits and limits) and applicable modality limits
Speech therapy and other therapy limits as specified in Schedule of Benefits

ALL of the following

No benefits for any Prescription not included in Company's Prescription Drug Formulary or Maintenance Drug Formulary; Disease Specific Drugs must be in Disease Specific Drug Formulary
All Prescription Drug Benefits are subject to Care Management including Prior Authorization which may be required prior to benefits being provided
Only maintenance formulary drugs eligible for 90-day supply; Category and pharmacy-specific copays apply per formulary rules

ALL of the following

Many specialty services and certain prescription drugs require Pre-Certification or Prior Authorization; benefits may be denied if Prior Authorization is not obtained
For certain services (for example transplants, TMJ), Members must receive Covered Services from Company-approved Network Providers and those Network Providers must obtain Prior Authorization to receive Network benefits

ALL of the following

Certain services are only covered at the higher benefit level when provided by designated Network/Center of Excellence or Blue Specialty Network Providers; Non-Network services often have reduced benefits or are not covered

Coverage criteria and exclusions

Summary of covered services and exclusions with Provider network distinctions and prior authorization conditions.

ALL of the following

Inpatient mental health/substance use disorder care coinsurance: Network = 80%; Non-Network = 60%
Outpatient hospital and other outpatient behavioral services: Network = 80%; Non-Network = 60%

ALL of the following

Inpatient rehabilitation services coinsurance: Network = 80%; Non-Network = 60% (Network inpatient rehab limited to 30 days/year)
Residential treatment center and partial hospitalization: Network = 80%; Non-Network = 60%

ALL of the following

Coding, Limits, and Procedural Constraints

Not specifiedmixed

Prescription Drug exclusionsmixedNot Covered

	Prescription and Medical Prescription Drug not included in the Prescription Drug Formulary, Maintenance Drug Formulary, Medical Prescription Drug Formulary or Disease Specific Drug Formulary
	Prescription Drugs and Medical Prescription Drugs determined by Company not to be Medically Necessary (including drugs for cosmetic purposes or weight reduction, drugs not proven effective in general medical practice, investigative drugs and drugs used other than for the FDA approved diagnosis except certain cancer drugs)
	Fertility drugs
	Minerals and vitamins (Exception: pre-natal vitamins)
	Nutritional supplements
	Drugs that do not require a prescription
	Contraceptive devices (Exception: prescription contraceptives and items required by the Patient Protection and Affordable Care Act)
	Prescription Drugs and Medical Prescription Drugs if an equivalent product is available over the counter
	Refills in excess of the number specified by the Physician or any refills dispensed more than one year after the date of Physician's original prescription

inv-05: Physical Medicine visit limit

LimitPhysical Medicine visits limited to 20 visits per Calendar Year (subject to Medical Necessity); three (3) modalities per visit

ScopeVisit limits apply to Physical Medicine visits in the home and at the Allied Specialist's office or facility

Network requirementNo Benefits for Physical Medicine services provided by Non-Network Physical Therapists, Occupational Therapists, or Chiropractors

inv-06: Inpatient rehabilitation limit

LimitInpatient rehabilitation services limited to 30 inpatient days per Calendar Year (Network)

Coinsurance

Provider Requirements and Prior Authorization

Prior Authorization

Transplant Prior Authorization

Prior Authorization Required — Transplant Network Benefits: In order for a Member to receive Network Benefits for covered transplant services, the Member must receive transplant services from a Network Provider approved and designated by the Company for that specific transplant procedure, and the Member's Network Provider must obtain Prior Authorization from the Company. Services provided by non‑approved or non‑network providers will not receive Network benefit levels.

Member must receive services from Company‑approved Network Provider for that transplant type
Network Provider must obtain Prior Authorization from the Company prior to the transplant
Non‑Network transplant services are generally not covered

Prior Authorization

Prescription Drug Prior Authorization

Prior Authorization and Care Management Required — Prescription Drug Benefits: All prescription drug benefits are subject to the Company's Prescription Drug Formulary and Care Management programs. Prior Authorization may be required before benefits are provided for certain drugs, including Disease‑Specific Drugs and other medications where prior authorization is a stated condition of benefit. Benefits will not be provided for drugs when prior authorization is required but not obtained.

Key Definitions

inv-14: Blue Primary Care Home

DefinitionBlue Primary Care Home: relationship with a Blue Primary Care Network Provider who provides coordinated and continuing care; Member should designate a Network Provider located and practicing in Mississippi (or in their state of residence if living outside Mississippi)

PediatricBlue Primary Care Home extends to Members ages 0 through 17, with care provided through a Pediatric Blue Primary Care Home

Provider selectionIf Member does not designate a Blue Primary Care Network Provider, the Company may designate one for the Member

inv-15: Specialty Services

DefinitionSpecialty Services: services subject to Medical Policy including Medical Necessity; coverage at higher benefit levels only when provided by a Center of Excellence Provider or a Blue Specialty Network Provider

Prior Authorization

Policy Summary

PayerBlue Cross Blue Shield - Mississippi

PolicyBlue Health Savings Certificate of Coverage (Schedule of Benefits)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization for specialty services and certain prescription drugs before benefits will be provided.

SourceLink

On This Page

Network benefits for transplants require all provisions be satisfied: Member must receive Covered Services from a Company-approved Network Provider and the Network Provider must obtain Prior Authorization

Other solid organ transplants (liver, heart, lung): Network = 80%; Non-Network = Not Covered

Tissue transplants (bone marrow): Network = 80%; Non-Network = Not Covered

Donor benefits are covered 100% when provided by a Network Provider; Donor benefits by Non-Network Provider not covered

ALL of the following

Temporomandibular/Craniomandibular Joint Disorder (TMJ): Prior Authorization required; No Benefits unless Network Provider obtains Prior Authorization
Diabetes supplies and equipment: Home glucose monitors limited to replacement every 2 years (Network coverage only); Network coinsurance = 80%
Diabetes self-management training limited to six (6) hours per Calendar Year (Network coverage only); Network coinsurance = 80%
Dilated eye exam and preventive routine foot care for diabetes limited to once per year (Network coverage only); Network coinsurance = 80%

Prescription drug coverage and exclusions

No benefits for any Prescription not included in Prescription Drug Formulary, Maintenance Drug Formulary, Medical Prescription Drug Formulary or Disease Specific Drug Formulary
No benefits for Disease Specific Drugs unless dispensed by a Network Disease Specific Pharmacy or approved non-pharmacy Network Provider and Prior Authorization obtained; Member receiving manufacturer financial assistance may be ineligible
Certain brand drugs may require trial of generic/ biosimilar before benefits are available; some drugs subject to quantity/day limits and medical policy
No benefits when Prior Authorization is required but not obtained; benefits may be reduced if manufacturer coupons are used

ALL of the following

Extensive exclusions include elective cosmetic procedures, infertility treatments, custodial/nursing home care, experimental procedures, many behavioral/educational programs, court-ordered non-medically necessary treatment, and medical marijuana (unless required by law)
Charges for eyeglasses, contact lenses, orthoptic therapy, and certain home modifications or convenience items are excluded
Nursing home care, custodial care, skilled nursing, long-term acute care, respite care, and related services are excluded

ALL of the following

All services are subject to Care Management and Medical Necessity determinations; services not recognized as accepted medical practice are excluded
Services provided by Non-Network independent laboratories or Non-Network providers may be excluded or paid at reduced benefit levels; Clinical trials performed by Non-Network Providers are excluded
Travel and lodging expenses for transplants are excluded unless criteria in Article XII are met

ALL of the following

Many services require Prior Authorization or Pre-Certification; benefits will not be provided without required Pre-Certification/Prior Authorization for Specialty Services and certain drugs
Certain high-benefit services (Specialty Services, Center of Excellence procedures, Disease Specific Drugs, transplant services) rely on use of designated Network Providers to obtain Network benefit levels

Inpatient rehabilitation (when covered as Hospital Services) paid at Network coinsurance level (typically 80%)

Non-NetworkNon-Network Provider for inpatient rehabilitation generally Not Covered

inv-07: Diabetes self-management training limit

LimitDiabetes self-management training limited to six (6) hours per Calendar Year

Benefit levelWhen rendered by a Network Provider, covered at Network coinsurance (80%)

Non-NetworkDiabetes self-management training provided by Non-Network Providers is Not Covered

inv-08: Home glucose monitor replacement frequency

FrequencyHome glucose monitors limited to replacement every 2 years

Benefit levelHome glucose monitor when provided by a Network Provider covered at Network coinsurance (80%)

Non-NetworkHome glucose monitors provided by Non-Network Providers are Not Covered

No benefits for prescriptions not included in the Company's Prescription Drug Formulary or Maintenance Drug Formulary
Certain drugs (e.g., Disease‑Specific Drugs) require Prior Authorization and may require dispensing by an approved Network Disease Specific Pharmacy
Drugs subject to step therapy, quantity/day limits, generic‑first policies, or trial of lower‑cost alternatives may require prior authorization or a documented trial
Failure to obtain required Prior Authorization will result in denial of drug benefits

No Benefits will be provided for Specialty Services without Pre-Certification or Prior Authorization

Network distinctionAmbulatory/Inpatient/Outpatient and Surgeon services receive higher coinsurance (e.g., 90%) when performed by Center of Excellence or Blue Specialty Network Provider; Non-Network often Not Covered

inv-16: Network Provider

DefinitionNetwork Provider (Transplant): a Network Provider approved and designated by the Company for the particular transplant surgery

Prior AuthorizationMember's Network Provider must obtain Prior Authorization from the Company for transplant Network benefits to be payable

Coverage implicationOther solid organ and tissue transplants are covered at Network levels (e.g., 80%) when performed by Company-approved Network Providers; Non-Network transplants are Not Covered

inv-17: Disease Specific Drug

DefinitionDisease Specific Drug: a drug that must meet the definition of a Disease Specific Drug and be listed in the Disease Specific Drug Formulary to be eligible for benefits

Dispensing requirementMust be dispensed by a Network Disease Specific Pharmacy or by a non-pharmacy Network Provider approved by the Company

Prior AuthorizationThe Network Provider must receive Prior Authorization from the Company for a Disease Specific Drug to be covered