Buffalo City School District Employee Health Insurance Enrollment Form Page 5
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15For questions specific to coverage contact: Blue Cross @ 887-8880 or 1-888-299-2263
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
Initial newborn exam and the first
6 well child visits covered for the
Well Child Care
baby’s first year, when using a
Covered in full.
Covered in full.
Covered in full.
participating provider. Additional
visits covered through age 19.
Insulin, oral agents, equipment,
Diabetic durable medical
and supplies covered after
Diabetic durable medical
Diabetic equipment and supplies
equipment - $5 copayment.
deductible and 20% copayment.
equipment - $8 copayment.
subject to $5 copayment. Insulin
Diabetic supplies up to a 30 day
For Major Medical type riders
Diabetic supplies up to a 30 day
and oral agents are covered,
supply - $5 copayment. Insulin
Diabetic Supplies
with a separate prescription drug
supply - $8 copayment. Insulin
subject to prescription drug or
up to a 30 day supply - $5
card, member may either pay
up to a 30 day supply - $8
office visit copayment, whichever
copayment or RX copayment,
prescription drug copayment or
copayment or RX copayment,
is less. Certain items are subject
whichever is less. No copay for
Major Medical copayment after
whichever is less.
to prior approval.
dependents under age 19.
deductible, whichever is less.
Covered. Participating doctors
$5 copayment. No copayment
Outpatient X-Ray
accept payment as payment in
Covered in full.
Covered in full.
for dependents under age 19.
full.
Covered. Participating doctors
Outpatient Laboratory and
accept payment as payment in
Covered in full.
Covered in full.
Covered in full.
Pathology
full.
Up to 30 days per member per
Detoxification covered in full for
year of inpatient hospitalization
Alcohol & Substance Abuse
Detoxification is covered in full.
Detoxification covered in full.
up to 7 days. Rehabilitation is not
for detoxification covered in full.
Inpatient
Rehabilitation is not covered.
Rehabilitation is not covered.
covered.
Inpatient rehabilitation is not
covered.
Covered for up to 60 outpatient
$8 copayment for up to 60
$5 copayment for up to 60
Alcohol & Substance Abuse
visits per calendar year covered.
$10 copayment for 60 visits per
outpatient visits per member per
outpatient visits per member per
Participating doctors accept
member per calendar year.
Outpatient
calendar year.
calendar year.
payment as payment in full.
Covered in full when medically
Covered in full when medically
Covered in full when medically
Covered in full when medically
Ambulance
necessary.
necessary.
necessary.
necessary.
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