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  • BCBS Pittsfield 2014 Benefit Comparison

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    A comparison of the health insurance benefits Pittsfield employees will receive through changing providers to Blue Cross Blue Shield.

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    A comparison of the health insurance benefits Pittsfield employees will receive through changing providers to Blue Cross Blue Shield.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    928 views10 pages

    BCBS Pittsfield 2014 Benefit Comparison

    Uploaded by

    iBerkshires.com
    A comparison of the health insurance benefits Pittsfield employees will receive through changing providers to Blue Cross Blue Shield.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 10

    MIIA / BCBSMA Active plan offerings (HMO NE and PPO)

    BENEFIT
    MIIA BCBSMA HMO Blue NE Deductible
    (Benchmark) MIIA BCBSMA Deductible BCEP PPO $250/$500/$750
    Rates: $539.58 Ind. / $1,415.32 Family Rates: $597.28 Ind. / $1,566.66 Family
    In-Network
    Deductible $250 Ind. / $750 family In - Network $250 one member /$500 two members/ $750 family for in-network and out of
    network combined
    Out-of-Pocket Maximum $2,500 per member,$5,000 per family, per plan year $2,500 per member/$5,000 per family for in and out of network combined
    medical claims only medical claims only
    Lifetime Benefit Maximum None None
    INPATIENT HOSPITAL YOU PAY YOU PAY
    General Hospital Nothing after Deductible for lower cost Hospitals
    $300 co-pay after Deductible for lower cost
    Hospitals
    (semi-private room $300 co-pay after Deductible for Higher cost Hospitals
    $700 co-pay after Deductible for Higher cost
    Hospitals
    and board and
    special services)
    Chronic Disease Hospital Nothing after deductible Nothing after deductible
    INPATIENT HOSPITAL YOU PAY YOU PAY
    Skilled Nursing Facility Nothing after deductible Nothing after deductible
    to 45 days per cal. Yr to 45 days per calendar year benefit maximum in & out-of-network combined
    Rehabilitation Hospital Nothing after deductible Nothing after deductible
    OUTPATIENT GENERAL HOSPITAL YOU PAY YOU PAY
    Emergency Room Visits $100 co-pay after deductible $100 per visit after deductible
    for Emergency or Accident care
    OUTPATIENT GENERAL HOSPITAL YOU PAY YOU PAY
    Emergency Room Visits $100 co-pay after deductible $100 per visit after deductible
    for Medical Care
    MIIA / BCBSMA Active plan offerings (HMO NE and PPO)
    MIIA / BCBSMA Active plan offerings (HMO NE and PPO)
    OUTPATIENT GENERAL HOSPITAL YOU PAY YOU PAY
    Surgery $100 co-pay after deductible $100 co-pay after deductible
    OUTPATIENT GENERAL HOSPITAL YOU PAY YOU PAY
    Radiation and Chemotherapy Nothing after deductible Nothing after deductible
    Diagnostic X-ray and Lab Nothing after deductible Nothing after deductible
    OUTPATIENT GENERAL HOSPITAL YOU PAY YOU PAY
    MRIs, CT & PET Scans,
    $100 co-pay (per category per date of service) after
    deductible $100 per category per date of service
    after deductible
    PHYSICIAN'S OFFICE YOU PAY YOU PAY
    Medical Care $20 per visit $20 per visit (no deductible) PCP
    $35 per specialist visit $35 per visit (no deductible) Specialists
    PHYSICIAN'S OFFICE YOU PAY YOU PAY
    Well Child Care Nothing Nothing
    Routine GYN Exam Nothing Nothing
    1 visit per calendar year 1 visit per calendar year
    Routine Vision Exam Nothing Nothing
    (1 visit per 24 months) 1 visit per 24 months in & out-of-network combined
    Adult Routine Physicals Nothing Nothing
    1 visit per 24 months in & out-of-network combined
    MENTAL HEALTH YOU PAY YOU PAY
    Inpatient admissions in a Nothing after Deductible for lower cost Hospitals
    $300 co-pay after Deductible for lower cost
    Hospitals
    general hospital $300 co-pay after Deductible for Higher cost Hospitals
    $700 co-pay after Deductible for Higher cost
    Hospitals
    MENTAL HEALTH YOU PAY YOU PAY
    Inpatient admissions in a $200 per admission after deductible $200 per admission after deductible
    mental hospital or
    MIIA / BCBSMA Active plan offerings (HMO NE and PPO)
    MIIA / BCBSMA Active plan offerings (HMO NE and PPO)
    substance abuse facility
    Outpatient mental health & $15 co-pay per visit $15 per visit
    substance abuse visits
    OTHER OUTPATIENT YOU PAY YOU PAY
    Physical & Occupational therapy
    $20 per visit up to 30 visits per calendar year benefit
    maximum for each type of therapy (90)
    $20 per visit up to 30 visits per calendar year
    benefit maximum for each type of therapy (90)
    OTHER OUTPATIENT YOU PAY YOU PAY
    Visiting Nurse & Nothing after deductible Nothing after deductible
    Home Health Care
    Durable Medical Nothing after deductible Nothing after deductible
    Equipment
    Emergency Ambulance Nothing after deductible Nothing after deductible
    OTHER OUTPATIENT YOU PAY YOU PAY
    Chiropractor Visits $20 co-pay per visit (up to 20 visits per cal yr) $20 co-pay per visit (up to 20 visits per cal yr)
    visit limit for in and out of network combined
    OTHER OUTPATIENT YOU PAY YOU PAY
    Prescription Drugs $10 for Tier 1 $10 for Tier 1
    $25 for Tier 2 $25 for Tier 2
    $50 for Tier 3 $50 for Tier 3
    to 30-day supply retail pharmacy to 30-day supply retail pharmacy
    $20 for Tier 1 $20 for Tier 1
    $50 for Tier 2 $50 for Tier 2
    $110 for Tier 3 $110 for Tier 3
    to 90-day supply mail service to 90-day supply mail service
    MIIA / BCBSMA Active plan offerings (HMO NE and PPO)
    MIIA / BCBSMA Active plan offerings (HMO NE and PPO)
    MIIA BCBSMA Deductible BCEP PPO $250/$500/$750
    Out of Network
    $250 one member /$500 two members/ $750 family for in-network and out of
    $2,500 per member/$5,000 per family for in and out of network combined
    None
    YOU PAY
    20% coinsurance after deductible
    20% coinsurance after deductible
    YOU PAY
    20% coinsurance after deductible
    to 45 days per calendar year benefit maximum in & out-of-network combined
    20% coinsurance after deductible
    YOU PAY
    $100 per visit dafter deductible
    YOU PAY
    $100 per visit dafter deductible
    MIIA / BCBSMA Active plan offerings (HMO NE and PPO)
    MIIA / BCBSMA Active plan offerings (HMO NE and PPO)
    YOU PAY
    20% coinsurance after deductible
    YOU PAY
    20% coinsurance after deductible
    20% coinsurance after deductible
    YOU PAY
    20% coinsurance after deductible
    YOU PAY
    20% coinsurance after deductible
    YOU PAY
    20% coinsurance after deductible
    20% coinsurance after deductible
    20% coinsurance after deductible
    1 visit per 24 months in & out-of-network combined
    20% coinsurance after deductible
    1 visit per 24 months in & out-of-network combined
    YOU PAY
    20% coinsurance after deductible
    YOU PAY
    20% coinsurance after deductible
    MIIA / BCBSMA Active plan offerings (HMO NE and PPO)
    MIIA / BCBSMA Active plan offerings (HMO NE and PPO)
    20% coinsurance after deductible
    YOU PAY
    20% coinsurance after deductible
    YOU PAY
    20% coinsurance after deductible
    20% coinsurance after deductible
    Nothing after deductible
    YOU PAY
    20% coinsurance after deductible
    YOU PAY
    MIIA / BCBSMA Active plan offerings (HMO NE and PPO)
    MIIA BCBSMA Sr. offerings
    OUTPATIENT GENERAL HOSPITAL YOU PAY
    Emergency Room Visits Nothing
    for Emergency or Accident
    Care
    Emergency Room Visits Nothing
    for Medical Care
    Surgery Nothing
    Radiation and Chemotherapy Nothing
    Diagnostic X-ray and Lab Nothing
    MRIs, CT & PET Scans, and Nothing
    Nuclear Cardiac Imaging
    Hemodialysis Nothing
    PHYSICIAN'S OFFICE YOU PAY
    Medical Care Nothing
    Routine GYN Exam Nothing
    (1 visit every 2 years)
    Routine Vision Exam Nothing when approved by Medicare
    Only when approved by Medicare
    Adult Routine Physicals Medicare provides coverage for one physical exam
    when enrolling into Medicare (one yearly no cost) when
    approved by Medicare
    MENTAL HEALTH YOU PAY
    MIIA BCBSMA Sr. offerings 7
    MIIA BCBSMA Sr. offerings
    Inpatient admissions in a Nothing
    general hospital
    Inpatient admissions in a Nothing
    mental hospital or
    substance abuse facility
    Outpatient mental health & Nothing
    substance abuse visits
    OTHER OUTPATIENT YOU PAY
    Physical & Occupational Nothing
    Therapy
    Visiting Nurse & Nothing
    Home Health Care
    Prosthetic Devices Nothing
    Durable Medical Nothing
    Equipment
    Emergency Ambulance Nothing
    Chiropractor Visits Nothing for manual manipulation of the spine to
    correct subluxation
    Prescription Drugs YOU PAY
    $10 for Tier 1
    $20 for Tier 2
    $35 for Tier 3
    to 30-day supply retail pharmacy
    $20 for Tier 1
    $40 for Tier 2
    $70 for Tier 3
    to 90-day supply retail pharmacy
    ** Sr. plans renew Jan. 1 each year due to CMS rules / CMS regulations govern plan benefits and pricing
    MIIA BCBSMA Sr. offerings 8
    MIIA BCBSMA Sr. offerings
    YOU PAY
    $50 per visit
    $50 per visit
    Nothing
    Nothing
    Nothing
    Nothing
    Nothing
    YOU PAY
    $10 per visit
    $10 per visit (1 visit per Cal Yr)
    $10 per visit( 1 visit per 24months
    $10 per visit
    YOU PAY
    MIIA BCBSMA Sr. offerings 9
    MIIA BCBSMA Sr. offerings
    Nothing
    Nothing
    Nothing
    YOU PAY
    $10 per visit
    Nothing
    $10 per item
    $10 per item
    Nothing for emergency
    $40 copay other when med nec.
    $10 per visit
    YOU PAY
    $10 for Tier 1
    $20 for Tier 2
    $35 for Tier 3
    to 30-day supply retail pharmacy
    $20 for Tier 1
    $40 for Tier 2
    $70 for Tier 3
    to 90-day supply retail pharmacy
    MIIA BCBSMA Sr. offerings 10

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