Us-Based Medical Benefits - Plan Comparison Chart Page 2
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1
2
3In-Network
Out-of-Network
HIP Health Plan
Benefits
AETNA
BLUE CROSS
AETNA
BLUE CROSS
of New York
2
(In-Network
Only)
MEDICAL BENEFITS
100%
100% after
100% after
80% after deductible
80% after deductible
Office/Home visits
$15/$20
$15/$20
PCP/Specialist
PCP/Specialist
co-pay
co-pay
100%
100% after
100% after
80% after deductible
80% after deductible
Routine Physical
once every
$15 co-pay once
$15co-pay once
once every 12 months
once every 12 months
12 months
every 12 months
every 12 months
100%
100%
100%
80% after deductible
80% after deductible
Surgery
PRESCRIPTION DRUGS
$5.00 for
20% co-pay up to
20% co-pay up to
US: 60% after
US: 60% after deductible
Pharmacy
generic/brand per
$20 per 30-day
$20 per 30-day
deductible
Int’l: 80% after deductible
30-day supply
supply
supply
Int’l: 80% after
deductible
$2.50 for
100% after $15
100% after $15 co-
N/A
N/A
Mail Order
generic/brand per
co-pay
pay
30-day supply
per 90-day supply
per 90-day supply
BEHAVIOURAL HEALTH CARE BENEFITS (must be pre-certified; benefit maximum for in-network and out-of-network
combined)
100%
100%
100%
100% after
80% after deductible
Inpatient Mental
Health Care
100%
100%
100%
80% after deductible
80% after deductible
Outpatient Mental
Health Care
100%
100%
100%
100% after
80% after deductible
Inpatient Alcohol
and Substance
Abuse Care
100%
100%
100%
80% after deductible
80% after deductible
Outpatient Alcohol
and Substance
Abuse Care
2
Please note that HIP Health Plan for New York is a “closed” plan and will not accept new participants except for new dependents of
subscribers currently enrolled in the plan.
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