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BTEIF Health Insurance Plans

HMO Blue 25 Excellus BlueCross BlueShield

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Network
4,700 Participating Physicians
All Hospitals within 25 counties
Description
With HMOBlue you receive first-class coverage with the value you need. Like low-cost doctor visits and a wide choice of doctors and specialists with access to all local hospitals. Plus get great discounts on health & wellness programs and products that will help you live a vital and healthy life. Its all part of our plan to bring you value everyday.
Hospital Inpatient Services
Hospital Services – $100 co-payment per admission for unlimited days of semi-private accommodations and all medically necessary services for acute care. Private room covered when medically necessary and authorized in advance by the HMOBlue Medical Director. All benefits paid in full after $100 per admission co-payment.
Inpatient Physical Rehabilitation of hospital and physician care. $100 co-payment for up to 60 days
Hospital Outpatient Services
Diagnostic X-Ray $40 co-payment per visit.
Diagnostic Laboratory and Pathology $25 co-payment per visit.
Surgical Care Facility: $50 co-payment per visit with Physician: $40 co-payment per visit
Pre-admission Testing Covered in full.
Prostate Cancer Screening $25 co-payment per visit
Routine Cervical Cancer Screening $25 co-payment per visit
Chemotherapy $25 co-payment per visit
Kidney Dialysis $25 co-payment per visit
Routine Mammography $25 co-payment per visit
Radiation Therapy $25 co-payment per visit
Emergency Services
Emergency Care $100 co-payment per visit for emergency medical conditions unless admitted within 24 hours.
Freestanding Urgent Care $35 co-payment per visit.
Ambulance (Ground Only) $100 co-payment.
Physician Services - Hospital Inpatient
Physician Visits Covered in full.
Surgery 20% coinsurance or $200 co-payment, whichever is less.
Anesthesia Covered in full.
Physician Services - Physician's Office
Diagnostic Office Visits PCP: $25 co-payment per visit. Specialist: $40 co-payment per visit.
Well Child Visits Covered in full, including immunizations, laboratory and other services ordered at the time of the visit, according to the American Academy of Pediatrics recommended schedule.
Routine Adult Physicals $25 co-payment per visit according to the National Medical Specialty recommended schedule.
Allergy Tests PCP: $25 co-payment per visit. Specialist: $40 co-payment per visit.
Allergy Injections PCP: $25 co-payment per visit. Specialist: $40 co-payment per visit.
Chemotherapy $25 co-payment per visit.
Radiation Therapy $25 co-payment per visit.
Diagnostic X-ray $40 co-payment per visit.
Diagnostic Laboratory and Pathology $25 co-payment per visit.
Maternity Care
Prenatal/Postnatal Office Visits $25 co-payment for the first 10 visits, remainder covered in full.
Hospital Charges for Mother $100 co-payment per admission.
Physician Charges for Mother Delivery – 20% coinsurance or $200 co-payment, whichever is less.
Newborn Nursery Care Covered in full, including physician charges.
Psychiatric and Chemical Dependence - Inpatient
Acute Psychiatric 100 co-payment per admission for up to 30 days of hospital and physician care per member per calendar year.
Chemical Dependence $100 co-payment per admission for up to 7 days of hospital and physician care per member per calendar year for detoxification only. Admissions for rehabilitation are not covered.
Psychiatric and Chemical Dependence - Outpatient
Acute Psychiatric Covered at 50% for up to 20 visits per member per calendar year. No coverage for ongoing psychotherapy, psychoanalysis, marital or family counseling or group therapy.
Chemical Dependence $25 co-payment per visit for up to 60 visits per member per calendar year.
Other Services
Skilled Nursing Facility $100 co-payment per admission for up to 45 days in semi-private accommodations and all medically necessary services. 360 days lifetime maximum. Custodial care is not covered. Co-payment is waived if member is admitted directly from a hospital admission.
Home Care Covered in full for up to 40 visits per calendar year when arranged by a HMOBlue Physician and approved by the HMOBlue Medical Director.
Hospice $100 co-payment per admission for up to 210 days in semi-private accommodations and all medically necessary services. This includes 5 visits for bereavement counseling. Custodial care is not covered. Co-payment is waived if member is admitted directly from a hospital admission
Physical, Speech, Occupational and Respiratory Therapy $40 co-payment per visit for up to a combined 30 visit maximum on physical speech, occupational and respiratory therapy per member per calendar year.
Cardiac Rehabilitation $40 co-payment per visit
Diabetic Supplies $25 co-payment for a one-month supply.
Chiropractic Services $40 co-payment per visit.
Hearing Aids $600 once every 3 years for children to age 19.
Second Surgical Opinion $40 co-payment per visit.
Durable Medical Equipment (DME) Standard equipment covered at 50% when purchased from a participating provider. No coverage if purchased from a non-participating provider.
Internal Prosthetics Covered in full.
External Prosthetics Standard equipment covered at 50% up to $15,000 per member per calendar year.
Dental $25 co-payment per visit when related to an accidental injury to sound, natural teeth and services are rendered within 12 months of the accident.
Prescription Drugs $10 Co-payment for Generic / $30 Co-payment for Preferred Brand Name / $50 co-payment for Non-Preferred Brand Name Drugs (Includes oral contraceptives)
Complementary amd Alternative Medicine Services
Acupuncture Services No coverage.
Massage Therapy No coverage.
Vision Care
Routine Eye Exams $40 co-payment per visit every 2 calendar years; children to age 19 covered every calendar year.
Eyewear No coverage. See BTEIF for Empire Vision Centers Group Discount program for members of BTEIF.
Health and Wellness Programs
Member Rewards is your connection to local health resources! Programs featuring massage therapy, biofeedback, nutrition and much more are available, and very affordable. The way you live your life today has a profound effect on your quality of life tomorrow - check out our ever expanding programs and services. Coverage provided worldwide when life threatening or authorized by your Primary Care Physician. If you become ill while traveling you will now have access to the BlueCard® Program. With BlueCard you have access to a provider finder 24 hours a day by calling 1-800-810-BLUE.
Out-of-Area Coverage
Guest Membership Coverage at an affiliated HMO when living away from home for at least 90 consecutive days.
Dependant Coverage Qualified dependents are covered to age 19.
Student Coverage Qualified Full-Time Students (minimum 12 credit hrs/semester) to age 23
Life Insurance $5,000 term life insurance policy via The Guardian on employee only.
Coinsurance None.
Annual Out-of-Pocket Maximum None.
Deductible None.
Lifetime Benefit Maximum Unlimited. Waiting periods for pre-existing conditions may apply.

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