blueshield of northeastern new york of northeastern new york our health plans all of our health...

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.

bsneny.com

NENYr_5131_09_12

BlueShield of Northeastern New York

Our health plans

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

✔ Health Advocate coaching service

✔ A variety of prescription copay options

✔ Multiple funding arrangements*

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

*HSAs only available with custom plans

Classic Blended CustomProduct Name HMO 109 Plus HMO 203 Plus PPO 842 E EPO 5226 EPO 4202 EPO 4204 PPO 6340 Healthy Balance

8000 Package 1Healthy Balance8000 Package 2

Healthy Balance8000 Package 3






Option 1 Option 2 Option 3 Option 4 Option 1 Option 2 Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 Option 7 Option 8 Option 9Type of Network HMO Local HMO Local PPO National EPO Local EPO Local EPO Local PPO National EPO National EPO National EPO National EPO National EPO Local EPO Local EPO Local EPO Local

In-Network

Deductible (single/true family) N/A N/A N/A N/A $1,000/$2,500 $1,500/$3,750 $3,000/$6,000 $1,500/$3,000 $2,000/$4,000 $5,000/$10,000 $3,000/$6,000 $1,500/$3,000 $2,000/$4,000 $5,000/$10,000 $3,000/$6,000

Coinsurance N/A N/A N/A N/A 20% 20% 30% 10% 20% 0% 20% 10% 20% 0% 20%

Out-of-Pocket Maximum (single/true family) N/A N/A N/A N/A $3,000/$7,500 $5,000/$12,500 $5,000/$10,000 $3,000/$6,000 $4,000/$8,000 $5,000/$10,000 $6,000/$12,000 $3,000/$6,000 $4,000/$8,000 $5,000/$10,000 $6,000/$12,000

Out-of-Network

Deductible (single/true family) $2,000/$4,000 $1,000/$2,000 $2,000/$4,000 N/A N/A N/A $5,000/$10,000 N/A N/A N/A N/A N/A N/A N/A N/A

Coinsurance 30% 30% 30% N/A N/A N/A 50% N/A N/A N/A N/A N/A N/A N/A N/A

Out-of-Pocket Maximum (single/family) $5,000/$10,000 $5,000/$10,000 $5,000/$10,000 N/A N/A N/A Unlimited N/A N/A N/A N/A N/A N/A N/A N/A

Medical ServicesPCP/Specialist Visit $30/$50 $15/$15 or $10/$20 $30/$50 $40/$60 $30/$50 $30/$50 $20* Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance

Well Child Visits and Immunizations 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 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Diagnostic X-Rays $50 $15/$20 $50 $60 20% coinsurance after deductible

20% coinsurance after deductible 30%* Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance

Chiropractic Care $50 $15/$20 $50 $60 $50 $50 $20* Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance

Women’s Services

Maternity CareCovered in full (after copay for

initial visit)

Covered in full (after copay for

initial visit)


initial visit)


initial visit)


initial visit)


initial visit)$20* Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance

Gynecological Office Visits (routine) 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 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 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 Covered in full Covered in full Covered in full

Hospital Care

Inpatient Hospital $1,000 $250 $1,000 $1,000 20% coinsurance after deductible

20% coinsurance after deductible

30%* Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance

Outpatient Surgery $75 $75 $300 $300 20% coinsurance after deductible

20% coinsurance after deductible

30%* Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance

ER Visit (copay waived if admitted to hospital) $100 $100 $200 $200 20% coinsurance after deductible

20% coinsurance after deductible $100* Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance

Urgent Care $35 $15/$20 $75 $75 $75 copay

no deductible$75 copay

no deductible $35* Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance

Other Services

Durable Medical Equipment 50% 50% 50% 50%50%

after deductible50%

after deductible 50%* Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance

Home Health Care (40 visits) $30 $15/$20 $30 $40 $30 $30 $20* Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Covered in full* Deductible & Coinsurance

Prosthetic Devices 50% 50% 50% 50%50%

after deductible50%


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 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 $15/$20 $50 $60 20%

after deductible20%


Prescription Drugs

Generic/Formulary/Non-Formulary Options Available Options Available Options Available Options Available Options Available Options Available Options Available* Options Available* Options Available*Covered in full

option available* Options Available* Options Available*Covered in full

option available* Options Available* Options Available*

Mail Order Drugs2.5 copays per 90-day supply

2.5 copays per 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 26/26 26/26 26/26 26/26 26/26 26/26

*after deductible

blueshield of northeastern new york of northeastern new york our health plans all of our health...

Documents