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Summary of Benefits and Coverage: What this Plan Covers ...
2021209U100116 Summary of Benefits and Coverage: What this Plan Covers &What You Pay for Covered Services Coverage Period: 01/01/2022 -12/31/2022 Blue Cross and Blue Shield of North Carolina: Blue Advantage Silver L$0 Deductible-3 Coverage for: Individual +Family Plan Type: PPO B0008135 1of 8 The Summary of Benefits and Coverage (SBC) document will help you …
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Formulary(L ist of Covered Drugs) - Blue Cross NC
www.bluecrossnc.comi When this drug list (formulary) refers to “we,” “us”, or “our,” it means Blue Cross and Blue Shield of North Carolina. When it refers to “plan” or “our plan,” it means Blue Medicare HMO Essential.
Durable Medical Equipment (DME) Providers for Breast Pumps ...
www.bluecrossnc.com® Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
Non-Formulary Exception Request Form - Blue …
www.bluecrossnc.comMembers HMO: Blue Cross and Blue Shield of North Carolina complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Medicare Part D Excluded Drug List - Blue Cross …
www.bluecrossnc.comMEDICARE PART D EXCLUDED DRUGS LIST 2016_updated July 2016 Reason: LIST = multiple reasons it's excluded; "not covered under Part D law". Reason: Not properly listed with FDA = CMS considers it best practice for Part D sponsors to consider the proper listing of a drug product with the FDA as a prerequisite for making a Part D …
Medicare C/D Medical Coverage Policy Electrical ...
www.bluecrossnc.comNeuromuscular Electrical Stimulation (NMES) involves the use of a device that transmits an electrical impulse to the skin over selected muscle groups by way of electrodes. Neuromuscular stimulator devices transmit an electrical impulse to
Corporate Medical Policy - Blue Cross NC
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www.bluecrossnc.com~ Prior Authorization Guidelines ~ Services marked by a bullet in the columns to the left require prior authorization for the designated line of
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PRESCRIBER NAME PRESCRIBER NPI [REQUIRED] …
www.bluecrossnc.comlast revision february 2017 infliximab (remicade®) prior review/certification faxback form incomplete forms may delay processing all nc providers must provide their 5-digit bcbsnc provider id# below
American Dental Association Claim Form - Blue …
www.bluecrossnc.comThe form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental The following information highlights certain form completion instructions.
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www.bluecrossnc.comThe medical policy consists of medical guidelines, including diagnostic imaging management policies, payment guidelines and evidence based guidelines.
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Summary of Benefits and Coverage: What this Plan Covers ...
www.cigna.comYour plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: North Carolina Department of Insurance at 1- 855-408-1212.
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