Building Trades Employers Insurance Fund
Insurance Forms
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BTEIF Health Insurance Plans
Excellus BlueCross BlueShield BluePPO HSA Option 2
Click here to print plan details.
| Plan Features | In Network | Out of Network |
|---|---|---|
| Primary Care Physician (PCP) | Not Required | Not Required |
| Referrals | Not Required | Not Required |
| Out of network benefits | N/A | at 60%, subject to the deductible. |
| Out of area benefits | Coverage provided worldwide through the BlueCard® program. | |
| Student/Dependent coverage | Dependents covered to age 19 / Qualified students to age 23. | |
| Plan Cost Sharing Highlights | In Network | Out of Network |
| Office visit copay (PCP) | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Office visit copay (Specialist) | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Coinsurance | 20% | 40% |
| Deductible | $2,000 Single / $4,000 Family Full family deductible must be met before services are covered | |
| Out of pocket maximum | $4,000 Single / $8,000 Family | |
| Lifetime maximum | None | |
| Plan Benefits - Preventive Healthcare Services | In Network | Out of Network |
| Well child visits | Covered in full | Covered in full |
| Adult routine physical exams | Covered in full | Covered at 60%, subject to the deductible |
| Adult immunizations | Covered in full | Covered at 60%, subject to the deductible |
| Mammography | Covered in full | Covered at 60%, subject to the deductible |
| Pap smear | Covered in full | Covered at 60%, subject to the deductible |
| Routine GYN Exam | Covered in full | Covered at 60%, subject to the deductible |
| Prostate cancer screening | Covered in full | Covered at 60%, subject to the deductible |
| Routine vision | Not Covered | Not Covered |
| Physician Services | In Network | Out of Network |
| Diagnostic office visits | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Diagnostic x-rays (MRI, PET, CAT scans)* | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Diagnostic laboratory and pathology | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Allergy tests | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Allergy injections | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Chemotherapy | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Radiation therapy | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Maternity Care | In Network | Out of Network |
| Prenatal and postpartum care | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Hospital care for mom (including delivery) | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Newborn nursery care | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Prescription Drugs | In Network | Out of Network |
| Short-term and maintenance drugs are covered under the coinsurance for each 30-day supply per prescription at participating retail pharmacies, up to a 90-day supply (with separate coinsurance for each 30-day supply) available through Express Scripts, Inc., mail order service. Contraceptives included. | Retail and Mail Order: Tier 1: 10% coinsurance Tier 2: 40% coinsurance Tier 3: 50% coinsurance Prescription drug benefits are subject to the medical plan deductible and out of pocket maximum. | Not Covered |
| Inpatient Hospital Benefits | In Network | Out of Network |
| Hospital benefits | Covered at 80%, subject to the deductible for unlimited days of room and board | Covered at 60%, subject to the deductible for unlimited days of room and board. |
| Physician visits in the hospital | Covered at 80%, subject to the deductible for unlimited visits | Covered at 60%, subject to the deductible for unlimited visits |
| Inpatient Physical Rehabilitation | Covered at 80%, subject to the deductible for 60 days per calendar year | Covered at 60%, subject to the deductible for 60 days per calendar year |
| Surgery | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Anesthesia | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Emergency Care | In Network | Out of Network |
| Emergency room care | Covered at 80%, subject to the deductible | Covered at 80%, subject to the deductible for emergency transportation |
| Freestanding urgent care center | Covered at 80%, subject to the deductible | Covered at 80%, subject to the deductible for emergency transportation |
| Ambulance | Covered at 80%, subject to the deductible for emergency transportation | Covered at 80%, subject to the deductible for emergency transportation |
| Outpatient Hospital Benefits | In Network | Out of Network |
| Diagnostic x-rays (MRI, PET, CAT scans)* | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Diagnostic laboratory and pathology | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Surgical Care | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Chemotherapy | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Radiation Therapy | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Mental Health and Chemical Dependence Benefits | In Network | Out of Network |
| Inpatient mental health care* | Covered at 80%, subject to the deductible for up to 30 days per calendar year | Covered at 60%, subject to the deductible for up to 30 days per calendar year |
| Outpatient mental health care | Covered at 50%, subject to the deductible for up to 20 visits per calendar year. | Covered at 50%, subject to the deductible for up to 20 visits per calendar year. |
| Inpatient chemical dependence care* | Covered at 80%, subject to the deductible for up to 7 days per calendar year for detoxification and 30 days per calendar year for rehabilitation. | Covered at 60%, 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 80%, subject to the deductible for up to 60 visits per calendar year. | Covered at 60%, subject to the deductible for up to 60 visits per calendar year. |
| Other Services | In Network | Out of Network |
| Diabetic insulin & supplies | Covered at 80%, subject to the deductible for a 30-day supply. | Covered at 60%, subject to the deductible for a 30-day supply. |
| Skilled nursing facility | Covered at 80%, subject to the deductible for up to 45 days per calendar year | Covered at 60%, subject to the deductible for up to 45 days per calendar year |
| Home care* | Covered at 80%, subject the deductible for unlimited visits per calendar year | 60%, subject to the deductible for unlimited visits per calendar year |
| Hospice | Covered at 80%, subject to the deductible for unlimited visits | Covered at 60%, subject to the deductible for unlimited visits |
| Outpatient therapy | Covered at 80%, subject to the deductible for up to 45 visits for physical, speech, occupational and respiratory therapy combined. | Covered at 60%, subject to the deductible for up to 45 visits for physical, speech, occupational and respiratory therapy combined. |
| Durable medical equipment* | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| External prosthetics | Covered at 80%, subject to the deductible up to $15,000 maximum per calendar year. | Covered at 60%, subject to the deductible up to $15,000 maximum per calendar year. |
| Chiropractic | Covered at 80%, subject to the deductible | Covered at 60%, subject to the deductible |
| Acupuncture | Not Covered | Not Covered |
| Dental | Covered at 80%, subject to the deductible for accidental injury to sound natural teeth. | Covered at 60%, subject to the deductible for accidental injury to sound natural teeth. |
| Hearing | Covered at 80%, subject to the deductible for diagnostic hearing exams. | Covered at 60%, subject to the deductible for diagnostic hearing exams |
Click here to print plan details.