Buffalo City School District Employee Health Insurance Enrollment Form Page 7

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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
Medical - $10 copayment per
Medical - $8 copayment per
office visit. Routine vision exam
office visit. One routine eye
once every two years with a $10
Covered for a $5 copayment.
Medical - covered by Major
exam will be covered once every
copayment for adults. Annual
Discounts on eyewear at Eye
Eye Care
Medical.* Routine vision
calendar year, subject to a
vision exam for children age 14
Med Vision providers. No copay
examinations are not covered.
copayment of $10. Discounts on
and under who have
for dependents under age 19.
eyewear at Eye Med Vision
documented refractive error.
providers.
Discount on eyewear at Eye Med
Vision providers.
Dual copayment prescription: $5
Three-tier prescription coverage:
Three-tier prescription coverage:
Three-tier prescription coverage:
generic, $10 name-brand. Oral
$5/$15/$30 copayment per
$5/$10/$25 copayment per
$5/$10/$25 copayment per
contraceptives are covered.
prescription for up to a 30 day
prescription for up to a 30 day
prescription for up to a 30 day
Prescriptions - Standard in
Accepted at all network
supply when written by a
supply when written by a
supply when written by a
Most Contracts
pharmacies. Contact
participating physician and filled
participating physician and filled
participating physician and filled
BCBSWNY for a list of all
at a participating pharmacy. Oral
at a participating pharmacy. Oral
at a participating pharmacy. Oral
network pharmacies.
contraceptives are covered.
contraceptives are covered.
contraceptives are covered.
Hospital stays covered up to 30
days per calendar year. Further
days covered in full by Major
Hospital stays covered in full for
Hospital stays and physician
Covered in full for up to 60 days
Mental Health Services
Medical. NY State operated
up to 30 days including 30
fees are covered in full for 30
per calendar year; 30 days per
Inpatient
psychiatric hospital covered for
physician visits per member per
days per member per calendar
admission.
30 days per member per year.
calendar year.
year for acute care.
Physicians' fees covered for all
covered inpatient days.
Covered for 20 visits per
Covered for up to 20 visits per
20 visits per member per
Mental Health Services
Covered in full for 40 visits per
member per calendar year. $5
calendar year. $8 copayment per
calendar year at the specialist
Outpatient
member per calendar year.
copayment per visit. No copay
visit.
copay
for dependents under age 19.

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