Buffalo City School District Employee Health Insurance Enrollment Form Page 6

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For 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
Services Without a Referral
Not applicable.
Not applicable.
Not applicable.
Not applicable.
Covered in full - 365 days by
basic hospital coverage. Further
Covered in full for unlimited
Covered in full for unlimited
Covered in full for an unlimited
Hospital Room & Board,
benefits covered by Major
number of days when medically
number of days when medically
number of days when medically
Services & Supplies
Medical (semi-private room
necessary.
necessary.
necessary.
allowance).
Covered in full if prior
Covered in full if prior
Covered in full if prior
Covered the same as in-area (all
Out-of-Area Hospital
authorization has been obtained.
authorization has been obtained.
authorization has been obtained.
BCBSWNY hospitals accept
Elective Admissions
If no prior authorization, payable
If no prior authorization, payable
If no prior authorization, payable
payment as payment in full).
under OON benefits.
under OON benefits.
under OON benefits.
Unlimited days for skilled level of
care by major medical when
Covered in full for up to 45 days
Covered in full for up to 45 days
Covered in full for up to 50 days
admitted to a participating facility
when admission is authorized by
when admission is authorized by
per member per year when
Skilled Nursing Facility
within 30 days of discharge from
BCBSWNY. Custodial care is
BCBSWNY. Custodial care is
admission is authorized by
a hospital if continued skilled
not covered.
not covered.
BCBSWNY.
care is medically necessary.
Custodial care is not covered.
Covered in full for up to 365
visits per calendar year from
$5 copayment per visit when
approved agencies in lieu of
$8 copayment per visit when
approved by BCBSWNY. No
Home Health Care
Specialist co-payment per visit.
hospital or Skilled Nursing
approved by BCBSWNY.
copay for dependents under age
Facility stay, when ordered by a
19.
physician.
$5 copayment per office visit.
Doctor’s Office Visits and
$5 PCP/$10 Spec.
Covered by Major Medical.*
$8 copayment per office visit.
No copay for dependents under
Plus Options: $0/$15 or $5/$10
Medical Checkups
age 19.
Covered by Major Medical to $50
$5 copayment per office visit.
per member per calendar year,
Routine Physicals
$8 copayment per office visit.
No copay for dependents under
PCP copayment per office visit.
not subject to deductible or
age 19.
coinsurance.

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