Post on 21-Apr-2018
BlueCross BlueShield of Western New York
Our health plans
A division of HealthNow New York Inc., an independent licensee of the BlueCross BlueShield Association.
The information in this document is not intended as a contract. Rates vary based on the overall benefit package and are subject to change without notice.
bcbswny.com
WNY_5131_09_12
All of our health plans offer the following benefits:✔ $0 copay on preventive care services
✔ Award-winning health and wellness programs for groups and individuals
✔ Worldwide coverage
✔ Discount programs available
✔ Out-of-network coverage
✔ Health Advocate coaching service
✔ A variety of prescription copay options
classic plans Plans that focus
on wellness and prevention while providing oustanding health care coverage
blended plans Plans that encourage
a healthy lifestyle by involving employees in health care decisions
custom plans Consumer-driven
plans that provide the greatest flexibility in health care coverage
Classic Blended CustomProduct Name HMO 109 Plus HMO 226 Plus Aqua POS 250 Blended Traditional 901 Slate POS 7100 Healthy Balance POS 8100 Healthy Balance PPO 8000 Denim 6150
Option 1 Option 2 Option 1 Option 2 Option 3 Option 1 Option 2 Option 3 Option 4In-Network
Deductible (single/true family) N/A N/A $500/$1,000 $1,000/$2,000 $250/$500 $1,500/$3,000 $1,500/$3,000 $2,000/$4,000 $5,000/$10,000
Coinsurance N/A N/A20% after Aqua allowance
and deductible 20% 80%/20% 0% 20% 20% 0%
Out-of-Pocket Maximum (single/true family) N/A N/A $2,500/$5,000 $5,000/$10,000 $500/$1,000 $5,000/$10,000 $4,000/$8,000 $5,000/$10,000 $5,000/$10,000
Out-of-NetworkDeductible (single/true family) $1,500/$3,000 $1,500/$3,000 $500/$1,000 $2,000/$4,000 N/A $1,500/$3,000 $1,500/$3,000 $2,000/$4,000 $5,000/$10,000
Coinsurance 40% 40% 50% after Aqua allowance and deductible
50% N/A 40% 40% 40% 50%
Out-of-Pocket Maximum (single/true family) $5,000/$10,000 $5,000/$10,000 $10,000/$20,000 $10,000/$20,000 N/A $10,000/$20,000 $10,000/$20,000 $10,000/$20,000 Unlimited
Medical Services
PCP/Specialist Visit $30/$50 $25/$40 20% after first $ coverage and deductible
$25/$40 20% after deductibleand coinsurance
$25/$40after deductible
Deductible/ Coinsurance
Deductible/ Coinsurance
Covered in full after deductible and coinsurance
Well Child Visits and Immunizations Covered in full Covered in full Covered in full after first $ coverage Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full
Diagnostic X-Rays $50 $40 20% after first $ coverage and deductible
20%subject to deductible Covered in full $40
after deductibleDeductible/ Coinsurance
Deductible/ Coinsurance
Covered in full after deductible and coinsurance
Chiropractic Care $50 $4020% after first $ coverage
and deductible $40 Variable - refer tobenefit summary
$40after deductible
Deductible/ Coinsurance
Deductible/ Coinsurance
Covered in full after deductible and coinsurance
Women’s Services
Maternity CareCovered in full (after copay for
initial visit)
Covered in full (after copay for
initial visit)
20% initial visit after first $ coverage and deductible, inpatient maternity stay - 20% after first $ coverage
$25 applies to initial visit only. Inpatient maternity stay - 20% subject to deductible
Covered in full$25 applies to initial visit only.
Inpatient maternity stay $750 after deductible
Deductible/ Coinsurance
Deductible/ Coinsurance
Covered in full after deductible and coinsurance
Gynecological Office Visits (routine) Covered in full Covered in full Covered in full after first $ coverage Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full
Mammograms (routine) Covered in full Covered in full Covered in full after first $ coverage Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full
Hospital Care
Inpatient Hospital $750 $500 20% after first $ coverage20%
subject to deductibleVariable - refer tobenefit summary
$750after deductible
Deductible/ Coinsurance
Deductible/ Coinsurance
Covered in full after deductible and coinsurance
Outpatient Surgery $150 $100 20% after first $ coverage and deductible
20%subject to deductible
Covered in full $150after deductible
Deductible/ Coinsurance
Deductible/ Coinsurance
Covered in full after deductible and coinsurance
ER Visit (copay waived if admitted to hospital) $150 $150 20% after first $ coverage
and deductible20%
subject to deductible Covered in full$150
after deductibleDeductible/ Coinsurance
Deductible/ Coinsurance
Covered in full after deductible and coinsurance
Urgent Care $35 $40 20% after first $ coverage and deductible
20%subject to deductible
Covered in full $50after deductible
Deductible/ Coinsurance
Deductible/ Coinsurance
Covered in full after deductible and coinsurance
Other ServicesWellness Allowance N/A N/A $250 N/A N/A N/A $250 $250 N/A
Durable Medical Equipment 50% 50%20% after first $ coverage
and deductible50%
subject to deductible20% after deductible
and coinsurance50%
after deductibleDeductible/ Coinsurance
Deductible/ Coinsurance
Covered in full after deductible and coinsurance
Home Health Care (40 visits) $30 $25 20% after first $ coverage and deductible $25 Covered in full $40
after deductibleDeductible/ Coinsurance
Deductible/ Coinsurance
Covered in full after deductible and coinsurance
Prosthetic Devices 50% 50% 20% after first $ coverage and deductible
50%subject to deductible
20% after deductibleand coinsurance
50%after deductible
Deductible/ Coinsurance
Deductible/ Coinsurance
Covered in full after deductible and coinsurance
Vision Exam (once every other year) Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full
Physical, Speech, and Occupational Therapy (30 aggregate visits) $50 $40 20% after first $ coverage
and deductible20%
subject to deductible20% after deductible
and coinsurance$40
after deductibleDeductible/ Coinsurance
Deductible/ Coinsurance
Covered in full after deductible and coinsurance
Prescription DrugsGeneric/Formulary/Non-Formulary Variety of options available Variety of options available Variety of options available Variety of options available Variety of options available Variety of options available Variety of options available Variety of options available Variety of options available
Mail Order Drugs 2.5 times copay for 90-day supply
2.5 times copay for 90-day supply
2.5 times copay for 90-day supply
2.5 times copay for 90-day supply Available, but not mandatory 2.5 times copay
for 90-day supply2.5 times copay
for 90-day supply2.5 times copay
for 90-day supply2.5 times copay
for 90-day supply
Dependent CoverageDependent/Student (until age) 26/26 26/26 26/26 26/26 26/26 26/26 26/26 26/26 26/26
Network HMO 100 HMO 200 POS 100 POS 200 POS 100 POS 100 PPO POS 100