HMO
A Division of Blue Cross of New York
SUMMARY OF COVERAGES

Single $345......Family $888 per month
BENEFIT IN-NETWORK
Dependent children To age 19: full-time student to age 23

Lifetime Benefit

Unlimited

Home/office visits for PCP and specialists

Well child care incl. immunizations

Well woman care

Diagnostic screening & mammography

Annual physical exam

$15 per visit

$0 co-pay

$15 co-pay

$0 co-pay

$15 co-pay
Inpatient care *
Physician visits

Unlimited days, semi-private room and board,surgery, surgical asst., anesthesiology, Lab & x-ray and MRIs*
$0 co-pay per visit

$500 co-pay per admission
Therapy (physical, occupational,speech and vision)
Inpatient therapy, physical medicine, or rehabilitation- 30 inpatient visits per calendar year

Up to 30 visits combined in home, office, or outpatient facility per calendar year

  

$500 co-pay per admission

$15 co-payment
Mental Health **

In hospital up to 30 days per calendar year

Up to 20 outpatient visits in office or facility per calendar year
$500 co pay per admission

$25 co-pay per visit
Substance Abuse **

In hospital up to 30 days detox/rehab per calendar year

Up to 60 outpatient visits which include 20 family counseling visits per calendar year

 ...

$500 co-pay per admission

$0
Alcohol Abuse** 
In hospital

Out of hospital
$500 Copay per admission


$5 co-payment
Outpatient Services
Ambulatory surgery*, surgery,pre-surgical testing, chemotherapy, radiation therapy, mammography, and cervical cancer screening

Second surgical opinion

kidney dialysis
$0 Copay
Emergency Room/facility***/Ambulance
$35 Copay, waived if admitted within 24 hours
Home Health Care*
up to 200 visits per calendar year

Home infusion therapy*

 $0 co-pay
Skilled nursing facility*

60 days per cal. year**
$0 co pay
Allergy testing & treatment
$15 co pay (waived for treatments)
Prescription Drugs***

$10 generic,$25 brand, $50 non formulary, $150 deductible per member
Chiropractic Care   

 20 visits per calendar year 

$15 Copay per visit
Hospice Care (210 days)
No charge
Cardiac rehabilitation
$15 Copay
Other coverages
Durable Equipment,medically necessary**

Medical supplies when medically necessary**
$0 co-pay
* PCP or provider must contact our medical management program to get pre-approved for this service

**Our behavorial health care management program must pre-approve all mental health and alcohol/substance abuse services.

***Our medical management program must be notified within 24 hours of visit