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BTEIF Health Insurance Plans

Excellus BlueCross BlueShield EPO Balance Option 6

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Benefits
Office visit co-payment $25/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 $25/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
Physician Services
Inpatient hospital physician visits Unlimited days paid in full
Surgery and anesthesia Paid in full
Diagnostic office visit $25 co-payment
Well child visits In compliance with New York State mandates - Paid in full
Adult routine physicals $25 co-payment
Allergy tests and injections $25 co-payment
Chemotherapy and radiation therapy Paid in full
Diagnostic x-ray, lab and pathology $25 co-payment
Maternity Care
Prenatal / Postnatal office visits $25 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. No inpatient rehabilitation benefits.
Outpatient psychiatric Up to 25 visits per member/calendar year covered at 50%.
Outpatient chemical dependence $25 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 $30 co-payment (30 day supply)
Tier 3: Non-preferred brand name drugs $50 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 $25 co-payment for a combined maximum of 40 visits/calendar year.
Respiratory therapy & Diabetic supplies $25 co-payment
Cardiac rehabilitation $25 co-payment
Chiropractic services $25 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 $25 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.

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