Buffalo City School District Employee Health Insurance Enrollment Form Page 8
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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
Covered in full when medically
$5 co-payment for unlimited
$5 copayment when medically
necessary. Participating
$8 copayment when medically
number of visits when medically
Chiropractic Services
necessary. No copay for
providers accept payment as
necessary.
necessary. No referral
dependents under age 19.
payment in full.
necessary.
Covered with a $5 member
Covered with an $8 member
copayment for medically
Covered for non-routine care.
Specialist copayment when
copayment for medically
necessary services. Routine foot
Podiatrists
Participating providers accept
medically necessary. Routine
necessary services. Routine foot
care is not covered. No
allowance as payment in full.
foot care is not covered.
care is not covered.
copayment for dependents under
age 19.
Covered by Major Medical on
Specialist co-payment per visit
$15 copayment per visit for short-
Covered with a $5 copayment for
doctor’s orders for short-term
for short-term restorative
Outpatient Rehabilitative
term restorative physical therapy
up to 30 visits per year. No
restorative physical therapy.
physical therapy; up to 20 visits
Therapy
for up to two consecutive months
copayment for dependents under
Participating providers accept
covered in a calendar year when
per diagnosis.
age 19.
the allowance as payment in full.
authorized by BCBSWNY.
Internal prostheses covered in
Internal prostheses covered in
Prosthetic Devices (Artificial
Internal is covered in full.
Covered by Major Medical.*
full. External not covered except
full. External not covered except
External covered at 50%.
Limbs, etc.)
for post-mastectomy prosthetics.
for post-mastectomy prosthetics.
Durable medical equipment is
covered at 20% copayment when
50% coinsurance, up to $1000
Not covered except for diabetic
Durable Medical Equipment
Covered by Major Medical.*
arranged for by a BCBSWNY
per member per calendar year.
equipment and supplies.
physician and received through a
participating provider.
Effective July 1, 2011: Generally, eligible dependents are covered to age 26, unless they have access to insurance through their
Unmarried Dependent
own employer, even if there is a cost associated.
Children
20% coinsurance, $250/$500
20% coinsurance, $200/$400
20% coinsurance, $250/$500
Out of Network
Not Applicable
deductible with an out of pocket
deductible with an out of pocket
deductible with an out of pocket
max of $2,000/$4,000
max of $3,000/$6,000
max of $2,000/$4,000
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