TRH Complete Care

Looking for a simple approach to complete health care coverage? Check into TRH Complete Care, which offers health, dental and vision coverage all under one plan.

With TRH Complete Care, you can enjoy the convenience of having health, dental and vision coverage as well as benefits for prescription drugs – all for one fee and all using the same TRH identification card.

TRH Complete Care uses BlueCross BlueShield of Tennessee (BCBST) to administer its claims. Plan members have access to BCBST’s Blue Network P for health benefits, which contains more than 21,000 providers in Tennessee. BCBST’s Dental Blue Preferred network is used for dental benefits.

TRH Complete Care Brochure

Learn more about:

• Covered Services
• Wellness Benefits
• Dental & Vision Benefits
• Benefit Schedule
• Cost-Saving Features
• Network Providers
• Plan Exclusions

Maternity benefits will be available only after family coverage has been in effect for nine consecutive months. There are no maternity benefits under individual coverage.

This information is an overview of the TRH Complete Care coverage. Please consult the TRH Complete Care Evidence of Coverage (EOC) for complete details of benefits, exclusions, and general provisions. All applications must be medically underwritten and approved before coverage is issued.

Covered Services

The following covered services and supplies are eligible expenses when they are medically necessary and appropriate, and prescribed and performed by an eligible provider for the diagnosis or treatment of an illness or accidental injury.

Hospital Inpatient Services – room, board and general nursing care; use of operating, delivery and treatment rooms; diagnostic services.

Hospital Outpatient Services – treatment of a sudden and serious illness or accidental injury; pre-admission testing; ambulatory surgery; diagnostic services.

Ambulance Services – benefits are available for ground and air ambulance. This plan provides benefits of 80 percent of the maximum allowable charge after the deductible is met. The maximum allowable charge is $450 for ground ambulance and $5,000 for air ambulance.

Physician Services – office visits; inpatient facility visits; surgery.

Diagnostic Services – radiology and pathology services.

Prescription Drugs – drugs prescribed by a licensed physician, approved by the FDA, dispensed by a licensed pharmacist, and unavailable for purchase without a prescription. Prescription drug benefits are subject to deductible.

Home Health Care – part-time or intermittent nursing care, physical therapy; home infusion therapy; oxygen. Benefits are limited to 45 visits per calendar year.

Behavioral Health Care - benefits are available for the treatment of mental or nervous conditions and substance abuse treatment. Benefits are limited to 50 percent with an annual maximum of $7,500 and a lifetime maximum of $30,000.

Organ Transplants – medically necessary and appropriate services for heart, heart/lung, bone marrow, lung, liver, pancreas, pancreas/kidney, kidney, small bowel, and small bowel/liver. There is a separate network of providers for transplant services. Prior authorization is required for services to be covered.

Wellness Benefits

Routine Physical Exam – After a six-month waiting period from the member’s effective date, benefits will be available up to $150 annually for members 7 years of age and above for a routine physical examination and related services when provided and billed by a network provider. No benefits are available for out-of-network provider services. Deductible, copayment and out-of-pocket maximums do not apply.

Annual OB/GYN Exam – benefits will be available for one routine OB/GYN exam per calendar year. Related pathology, including pap smear, which is provided as a part of the routine OB/GYN exam, will be covered. No benefit is available for routine OB/GYN exams provided by an out-of network provider.

Child Health Supervision Services – benefits are available for a member under 7 years of age for physical examinations and appropriate immunizations/vaccinations rendered by a network provider. Services include history, physical exam, developmental assessment, anticipatory guidance, and appropriate immunizations and laboratory tests, in keeping with prevailing medical standards. No benefit is available for the examinations and immunizations if provided by an out-of-network provider.

Annual Routine PSA – benefits will be provided for one routine PSA per calendar year when services are rendered by an independent laboratory or other outpatient setting.

Annual Routine Pap Smear – benefits will be provided for the interpretation of one routine pap smear per calendar year when services are rendered by an independent laboratory or other outpatient setting.

Routine Colonoscopy – benefits will be provided for one routine colonoscopy every four years for members age 50 and over.

Dental Benefits

After a six-month waiting period from a member’s effective date of coverage, benefits are available for necessary dental care services performed by a doctor of dental surgery (DDS), a doctor of medical dentistry (DMD) or any physician licensed to perform covered dental procedures.

Benefits are subject to a $25 copayment per visit and a $500 calendar year maximum.

Covered services include:

• Routine periodic examinations, two in a 12-month period.
• Bitewing x-rays once in a 12-month period.
• Full mouth x-rays, once in a 36-month period.
• Topical fluoride application for dependent children under age 19, once in a 12-month period.
• Prophylaxis and periodontal maintenance, two in a 12-month period.
• Sealants, only for occlusal (biting) surface of the first and second permanent molar teeth on members under 16 years of age.
• Restorative services – filling material such as amalgam, synthethic porcelain and composite restorations.
• Emergency treatment for relief of pain.
• Extraction of impacted and non-impacted teeth.

Vision Benefits

After a six-month waiting period from a member’s effective date of coverage, benefits are available for routine eye examinations, eyeglasses and contact lenses.
Benefits for eye examinations are limited to $40 per member per calendar year.

Benefits for eyeglasses or contact lenses are limited to $100 per member per calendar year.

Benefit Schedule

	Network Providers	Out-of-Network Providers
Calendar Year Deductible Per Person	$1,500
Coinsurance	80%	60%
Out of Pocket Maximum Individual Family	$7,500 $15,000	Unlimited Unlimited
Office Visit Copayment	$25	Not applicable
Prescription Drugs Generic Brand Name	100% 75%	60% 60%
Behavioral Health Care Coinsurance Annual Maximum Lifetime Maximum	50% $7,500 $30,000
Lifetime Maximum Per Person	$2,000,000

Copayments do not apply to the following services: All maternity services, all therapeutic services, allergy testing and injections, behavioral health care services, biopsy interpretations, bone density testing, cardiac diagnostic testing, chemotherapy services, chiropractic services, CT scans, CTA scans, dental services, diagnostic services sent out, DME and DME supplies, growth hormone injections, IV therapy, Lupron injections, mammography, MRI, MRA, MRS, nerve conduction studies, neuropsychological or neurological tests, nuclear cardiology, nuclear medicine, orthotics, PET scans, prosthetics, provider administered specialty pharmacy products, sleep studies, surgery performed in a physician's office and related surgical supplies, Synagis injections, and ultrasounds. These services will be covered under normal contract benefits, subject to the terms and conditions of the EOC. Deductibles and coinsurance will apply.Copayments do not apply toward satisfying deductibles, out-of-pocket maximum, or maximum lifetime amounts. Once the deductible and out-of-pocket maximum are met, copayments still apply.

Cost-Saving Features

Prior Authorization – The purpose of prior authorization is solely to ensure patients receive services at the appropriate time and in the appropriate setting. A prior authorization confirmation is not a guarantee of benefits. Benefits are based on all terms and conditions of the coverage in force at the time services are provided.

Prior authorization is required for all inpatient hospital stays. Failure to obtain prior authorization will result in benefits being reduced. (Network hospitals cannot bill patients for services when they fail to obtain prior authorization.)

Prior authorization is also required for home health care, home infusion therapy, allergy testing, private duty nursing, skilled nursing facility, hospice home care, prosthetic appliances, transplants, certain high-tech imaging, physical therapy when performed at home, inpatient behavioral health care services and certain prescription drugs.

Care Management – Care management provides cost-effective treatment alternatives for patients with complicated, chronic, and/or catastrophic illnesses or injuries. Care management involves a systematic process of assessing, planning, service coordination, and monitoring through which multiple needs of patients are met.

Concurrent Utilization Review – The goal of concurrent utilization review is to encourage the appropriate use of hospitalization.

Network Providers

The Blue Network P offers members a network of hospitals, physicians, ambulatory surgical facilities, home health agencies, pharmacies and other providers. For dental services, TRH Complete Care uses the Dental Blue Preferred Network. Network providers have agreed to special pricing arrangements. When using network providers, members are responsible for applicable copayments, deductibles and coinsurance for covered services.

When using an out-of-network provider, a member’s benefits may be substantially reduced and out-of-pocket expenses may be higher. There are no limits to a member’s out-of-pocket expenses when using out-of-network providers.

Blue Network P Provider Directory

Dental Blue Preferred Provider Directory

Eligible transplant services use a separate Transplant Network of providers. To receive the highest level of benefits for eligible transplant services, members must use the Transplant Network. Transplant services require prior authorization. For a list of Transplant Network Providers contact the administrator, BlueCross BlueShield of Tennessee.

Plan Exclusions

To keep TRH Complete Care coverage affordable, there are some services that are not covered. The Evidence of Coverage provides complete details of benefits, exclusions, limitations and other plan provisions.

Pre-Existing Waiting Period – benefits will not be provided for any pre-existing condition until a member has completed a waiting period of 12 months. A pre-existing condition is defined as an illness, injury, pregnancy, or any other medical condition which existed at any time preceding the effective date of coverage for which medical advice or treatment was recommended by, or received from, a provider of health care services or symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment.

Maternity Benefits – benefits are available after TRH family coverage has been in effect for nine consecutive months. There are no maternity benefits on individual coverage.

Benefit Exclusion Rider – TRH underwriting guidelines may deem it necessary to attach a benefit exclusion rider to a member’s coverage. A benefit exclusion rider means a specific condition is excluded from coverage for a specified length of time.

Plan Exclusions

This information is an overview of the TRH Complete Care coverage. Please consult the TRH Complete Care Evidence of Coverage (EOC) for complete details of benefits, exclusions, and general provisions. All applications must be medically underwritten and approved before coverage is issued.

Call your local TRH Representative today or Contact Us.