Buffalo City School District Employee Health Insurance Enrollment Form Page 4
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15For questions specific to coverage contact: Blue Cross @ 887-8880 or 1-888-299-2263
Plan Comparison - BTF
Plan C - Plan of benefits
Plan B - Plan of benefits
Plan D - BC/BS POS
CATEGORY
Plan A - BC/BS Traditional
formerly offered through
formerly offered through IHA
Community Blue
Univera
Covered. Participating doctors
Surgeon/Anesthesiologist
accept payment as payment in
Covered in full.
Covered in full.
Covered in full.
Fees (Inpatient/Outpatient)
full.
Covered. Participating doctors
Doctor’s Fees for Maternity
accept payment as payment in
Covered in full.
Covered in full.
Covered in full.
Care
full.
Elective cosmetic surgery is not
Elective cosmetic surgery is not
Elective cosmetic surgery is not
covered. We will, however,
covered. We will, however,
covered. We will, however,
Covered when required and
provide coverage for services in
provide coverage for services in
provide coverage for services in
Cosmetic Surgery
necessary as determined by the
connection with reconstructive
connection with reconstructive
connection with reconstructive
insured's physician
surgery per BCBSWNY medical
surgery per BCBSWNY medical
surgery per BCBSWNY medical
guidelines.
guidelines.
guidelines.
Covered for 365 daily visits.
Participating doctors accept
Doctor’s Hospital Visits
payment as payment in full.
Covered in full.
Covered in full.
Covered in full.
Further visits covered by Major
Medical.*
Covered. Two per admission.
Participating doctors accept
payment as payment in full.
Covered in full.
Covered in full.
Covered in full.
In-Hospital Consultations
Further consultations may be
approved or will be covered by
Major Medical.*
Hospital charges covered in full.
$35 copayment for worldwide
Surgical procedures and related
$25 copayment for worldwide
emergency room (ER) use
$35 copayment for emergency
services covered. Covered in full
emergency room use.
including physicians’ fees for life
Emergency Services
room. Copayment is waived if
up to $100 per calendar year,
Copayment is waived if patient is
threatening emergencies.
admitted.
with additional benefits under
admitted.
Copayment for emergency room
Major Medical.
waived if admitted.
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