Building Trades Employers Insurance Fund
Insurance Forms
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BTEIF Health Insurance Plans
Excellus BlueCross BlueShield EPO Balance Option 1
Click here to print plan details.
| Health Services | ||
|---|---|---|
| Primary Care Physician (PCP) | Not required | |
| Referrals | Not required | |
| Out of network benefits | Not covered | |
| Out of area benefits | Coverage provided worldwide through the BlueCard program. | |
| Student/Dependent coverage | Dependents covered to age 19. Qualified students covered to age 23. | |
| Plan Cost Sharing Highlights | ||
| Office visit copay (PCP) | $15 | |
| Office visit copay (Specialist) | $15 | |
| 85/15 Coinsurance | Member 15% – Insurance Company 85% | |
| Deductible | $500 per member/$1,500 per family | |
| Out of pocket maximum | $1,500 per member/$4,500 per family | |
| Lifetime maximum | None | |
| Plan Benefits - Preventive Healthcare Services | ||
| Well child visits | Covered in full | |
| Adult routine physical exams | $15 copay | |
| Adult immunizations | Not covered | |
| Mammography | Covered in full | |
| Pap smear | Covered in full | |
| Routine GYN Exam | Covered in full | |
| Prostate cancer screening | Covered in full | |
| Routine vision | $15 copay for one routine eye exam every 2 years. | |
| Physician Services | ||
| Diagnostic office visits | $15 copay | |
| Diagnostic x-rays | Covered at 85%, subject to the deductible | |
| Diagnostic laboratory and pathology | $15 copay | |
| Allergy tests | $15 copay | |
| Allergy injections | $15 copay | |
| Chemotherapy | Covered at 85%, subject to the deductible | |
| Radiation therapy | Covered at 85%, subject to the deductible | |
| Maternity Care | ||
| Prenatal and postpartum care | $15 copay | |
| Hospital care for mom | Covered at 85%, subject to the deductible (including delivery) | |
| Newborn nursery care | Covered at 85%, subject to the deductible | |
| Prescription Drugs | ||
| Short-term and maintenance drugs are covered under the following co-payments for each 30 day supply per prescription at participating retail pharmacies, up to a 90-day supply (with separate copays for each 30-day supply) available through Express Scripts, Inc., mail order service. | Retail and Mail Order: Tier 1: $10 copay Generic Tier 2: $30 copay Preferred Brand Name Tier 3: $50 copay Non-Preferred Brand Name (includes oral contraceptives) Generic drugs: $0 copay for children up to 19! |
|
| Inpatient Hospital Benefits | ||
| Hospital benefits | Covered at 85%, subject to the deductible for unlimited days of room and board. | |
| Physician visits in the hospital | Covered at 85%, subject to the deductible for unlimited visits | |
| Inpatient Physical Rehabilitation | Covered at 85%, subject to the deductible for up to 60 days per calendar year. | |
| Surgery | Covered at 85%, subject to the deductible | |
| Anesthesia | Covered at 85%, subject to the deductible | |
| Outpatient Hospital Benefits | ||
| Diagnostic x-rays | at 85%, subject to the deductible | |
| Diagnostic lab and pathology | $15 copay | |
| Surgical Care | at 85%, subject to the deductible | |
| Chemotherapy | at 85%, subject to the deductible | |
| Radiation Therapy | at 85%, subject to the deductible | |
| Emergency Care | ||
| Emergency room care | $50 copay per visit unless admitted within 24 hours. | |
| Freestanding urgent care center | $25 copay | |
| Ambulance | $50 copay for emergency transportation. | |
| Mental Health and Chemical Dependence Benefits | ||
| Inpatient mental health care | Covered at 85%, subject to the deductible for up to 30 days per calendar year. | |
| Outpatient mental health care | Covered at 50%, for up to 20 visits per calendar year. Not subject to the deductible. | |
| Inpatient chemical dependence care | Covered at 85%, subject to the deductible for up to 7 days per calendar year for detoxification and 30 days per calendar year for rehabilitation. | |
| Outpatient chemical dependence care | Covered at 85%, subject to the deductible for up to 60 visits per calendar year. | |
| Other Services | ||
| Diabetic insulin & supplies | $15 copay | |
| Skilled nursing facility | Covered at 85%, subject to the deductible for up to 45 days per calendar year. | |
| Home care | Covered at 85%, subject to the deductible for unlimited visits. | |
| Hospice | Covered at 85%, subject to the deductible for unlimited days. | |
| Outpatient therapy | Covered at 85%, subject to the deductible for up to 40 visits for physical, speech, occupational and respiratory therapy combined. | |
| Durable medical equipment | Covered at 50%. Not subject to the deductible. | |
| External prosthetics | Covered at 50% up to a $15,000 maximum per calendar year. Not subject to the deductible. | |
| Chiropractic | $15 copay | |
| The Guardian Life Insurance Plan | $5,000 term life insurance policy for employee only | |
| Dental | $15 copay for accidental injury to sound natural teeth. | |
| Hearing | $15 copay for diagnostic hearing exams. | |
| Participating Providers | Over 579,00 participating providers and hospitals throughout the US (86%) via BlueCard program. | |
Click here to print plan details.