Building Trades Employers Insurance Fund
Insurance Forms
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BTEIF Health Insurance Plans
Excellus BlueCross BlueShield EPO Balance Option 5
Click here to print plan details.
| Benefits | ||
|---|---|---|
| Office visit co-payment | $20/visit co-payment - Paid in full thereafter | |
| Lifetime maximum benefit | Unlimited | |
| Deductible | None | |
| Coinsurance | None | |
| Annual out of pocket maximum | None | |
| Hospital Inpatient Services | ||
| Semi-private room & board | Unlimited days of semi-private accommodations and all medically necessary services for acute care are paid in full. Private room when medically necessary. | |
| Inpatient Physical Rehabilitation | 60 days of semi-private accommodations and all medically necessary services paid in full. | |
| Surgery & Anesthesia | Paid in full | |
| Outpatient Services | ||
| Diagnostic X-rays, laboratory, pathology | $20/visit co-payment | |
| Surgical care | $50 co-payment | |
| Pre-admission testing | Paid in full | |
| Routine Mammography | mammograms paid in full | |
| Routine cervical cancer screening | Paid in full | |
| Chemotherapy and radiation therapy | Paid in full | |
| Kidney dialysis | Paid in full | |
| Emergency Care | ||
| Emergency care | Emergency room care for emergency medical conditions subject to $50 co-payment. Co-payment waived if admitted within 24 hours. | |
| Freestanding urgent care | $25 co-payment | |
| Ambulance | $50 co-payment per trip | |
| Ambulance | $50 co-payment per trip | |
| Physician Services | ||
| Inpatient hospital physician visits | Unlimited days paid in full | |
| Surgery and anesthesia | Paid in full | |
| Diagnostic office visit | $20 co-payment | |
| Well child visits | In compliance with New York State mandates - Paid in full | |
| Adult routine physicals | $20 co-payment | |
| Allergy tests and injections | $20 co-payment | |
| Chemotherapy and radiation therapy | Paid in full | |
| Diagnostic x-ray, lab and pathology | $20 co-payment | |
| Maternity Care | ||
| Prenatal / Postnatal office visits | $20 co-payment | |
| Hospital & physician charges for mother | Paid in full | |
| Anesthesiologist & newborn nursery care | Paid in full | |
| Chemical Dependence | ||
| Inpatient acute psychiatric * | Up to 30 days of hospital and physician care per member/calendar year covered in full | |
| Inpatient chemical dependence * | Up to 7 days of hospital and physician care per member/calendar year. For detoxification covered in full. Up to 30 days per member/calendar year for rehabilitation covered in full. | |
| Outpatient psychiatric | Up to 20 visits per member/calendar year covered at 50%. | |
| Outpatient chemical dependence | $20 copay for up to 60 visits per member/calendar year. | |
| Prescription Drugs | ||
| Tier 1: Generic | $10 co-payment (30 day supply). $0 co-payment for children to age 19 | |
| Tier 2: Preferred brand name drugs | $25 co-payment (30 day supply) | |
| Tier 3: Non-preferred brand name drugs | $40 co-payment (30 day supply) | |
| Contraceptives | Yes | |
| Mail order | Up to 90 day supply available via Express Scripts, Inc. | |
| Other Services | ||
| Home health care & Hospice | Unlimited days paid in full * | |
| Physical, speech & occupational therapy | $20 co-payment for a combined maximum of 40 visits/calendar year. | |
| Respiratory therapy & Diabetic supplies | $20 co-payment | |
| Cardiac rehabilitation | $20 co-payment | |
| Chiropractic services | $20 co-payment | |
| Second surgical opinion | Paid in full | |
| Durable medical equipment | Covered at 80% * | |
| External prosthetics | Covered at 80%. $15,000 maximum payment/member/calendar year. | |
| Elective sterilization | Paid in full | |
| Dental | $20 co-payment for accidental injury to sound natural teeth. | |
| Out of area coverage | provided world-wide through BlueCard PPO program. | |
| Freedom of Choice of Providers | Member may use any local or national provider who participates with any local BlueCross BlueShield PPO program. No referrals. | |
| Dependent coverage | All qualified dependents and/or students to age 23 covered. | |
| Participating Providers | 85 % of all doctors/providers locally and nationally participate. | |
| Life Insurance (The Guardian) | BTEIF provides a $5,000 term death benefit on covered employee. Benefits insured through The Guardian Life Insurance Company, not Excellus BlueCross BlueShield. Claims submitted to the BTEIF. | |
| Limitations | ||
| Precertification (*) | * indicates precertification is required in order to be eligible for maximum benefits, unless it is a medical emergency. | |
| Employer / Employee Participation | 75% of an employer’s eligible employees must enroll in EPO plan. | |
| Out of network benefits | There are no benefits for services rendered by nonparticipating providers. | |
| Enrollment | All applications/information must be received by BTEIF no later than the 10th of the month prior to the employer’s requested enrollment date. | |
| Pre-existing conditions | Waiting period for pre-existing conditions may apply unless employee and/or dependents have had prior coverage during the past 330 days, without a lapse of coverage greater than 63days. | |
Click here to print plan details.