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MEDICAL PLAN FOR RETIREES UNDER AGE 65, EFFECTIVE 1-1-99

EMPIRE DELUXE PPO BENEFIT SUMMARY

BENEFIT

IN-NETWORK1

OUT-OF-NET WORK2

COST SHARING

Employee Pays

Employee Pays

DEDUCTIBLE

Not Applicable

Option 1: $200/$500

COINSURANCE

Not Applicable

30%

COINSURANCE STOP-Loss

Not Applicable

$10,000/$25,000 ($3,000/$7,500 out-of-pocket)

DEPENDENT CHILDREN

To age 19; full-time students to age 25

LIFETIME MAXIMUM

Unlimited

$1 ,000,000

HOSPITAL BENEFITS3 Employee Pays Employee Pays
INPATIENT4 (Except Mental Health) Unlimited
days-semiprivate room and board

$0

Deductible and coinsurance

INPATIENT PHYSICAL THERAPY, PHYSICAL MEDICINE OR REHABILITATION4
30 inpatient days per calendar year

$0

Deductible and coinsurance

MENTAL HEALTH5
Up to 30 days per calendar year

$0

Covered in-network only

ALCOHOL/SUBSTANCE ABUSE5
Up to 7 days detox per calendar year

$0

Covered in-network only

OUTPATIENT4
Ambulatory surgery , pre-surgical testing, chemotherapy, radiation therapy, mammography, and cervical cancer screening

$0

Deductible and coinsurance

EMERGENCY ROOM/FACILITY
Initial visit for emergency care4

$35 copay (Waived if admitted within 24 hours)

OTHER FACILITY BENEFITS3

Employee Pays

Employee Pays

ALCOHOL/SUBSTANCE ABUSE5
Up to 60 outpatient visits which include 20 family counseling visits per calendar year

$0

Deductible and coinsurance

HOME HEALTH CARE4
Up to 200 visits per calendar year

$0

Coinsurance
(Deductible does not apply)

HOME INFUSION THERAPY4

$0

Covered in-network only

OUTPATIENT KIDNEY DIALYSIS

$0

Deductible and coinsurance

HOSPICE4
Up to 210 days per calendar year

$0

Covered in-network only

SKILLED NURSING FACILITY4
Up to 60 days per calendar year

$0

Covered in-network only

1 Network provider delivers care.

2 Subject to balance billing over allowed amount.

3 Out-of-network services (except Mental Health and Alcohol/Substance Abuse) are those from a provider that does not participate with Empire or with another Blue Cross and Blue Shield Plan through the BlueCard  PPO Program. [This does not apply to emergency benefits. See (5) for Mental Health and Alcohol/Substance Abuse services.]

4 Precertification by our Medical Management Program is required. If not obtained, penalties will apply.

5 Our Behavioral Health Care Management Program must pre-approve all Mental Health and Alcohol/Substance Abuse services.

6Copay does not apply if the Second Surgical Opinion is arranged through our Medical Management Program.

NOTE: This is a benefit summary only and is subject to the terms, conditions, limitations, and exclusions set forth in the contract. Failure to comply with our Medical Management or Behavioral Health Care Management Programs could result in benefit reductions.  
PLEASE NOTE: A penalty of 50% of hospital and doctor bills on the Empire Deluxe program up to a maximum of $2,500 per admission/visit if precertification is not obtained.

 

BENEFIT

IN-NETWORK 1

OUT-OF-NET WORK2

 

MEDICAL BENEFITS3

Employee Pays

Employee Pays

HOME/OFFICE VISITS

$12 copay (Network physician)

Deductible and coinsurance

ANNUAL PHYSICAL EXAM

$12 copay

Covered in-network only

WELL CHILD CARE (Up to age 19; including necessary immunizations)

$0

Deductible and coinsurance

WELL WOMAN CARE

$12 copay

Deductible and coinsurance

INPATIENT VISITS

$0

Deductible and coinsurance

DIAGNOSTIC SCREENING & MAMMOGRAPHY

$0

Deductible and coinsurance

MATERNITY

$0

Deductible and coinsurance

SURGERY

$0

Deductible and coinsurance

SURGICAL ASSISTANT

$0

Deductible and coinsurance

ANESTHESIOLOGY

$0

Deductible and coinsurance

LAB & X-RAY

$0

Covered in-network only

MRI4

$0

Covered in-network only

MENTAL HEALTH5
Up to 20 outpatient visits in office or facility per calendar year Up to 30 inpatient visits per calendar year

$25 copay per visit


$0

Covered in-network only


Covered in-network only

ALLERGY TESTING & TREATMENT

$12 copay (Waived for treatments)

Deductible and coinsurance

SECOND SURGICAL OPINION

$12 copay6

Deductible and coinsurance

PHYSICAL THERAPY4
Up to 30 visits as an inpatient & 30 visits combined in home, office, or outpatient facility

$12 copay

Covered in-network only

OTHER THERAPIES4 (Occupational, speech, vision) Combined 30 visits in home, office, or outpatient facility

$12 copay

Covered in-network only

CARDIAC REHABILITATION4

$12 copay

Deductible and coinsurance

MEDICAL SUPPLIES

Not applicable

$0

DURABLE MEDICAL EQUIPMENT, PROSTHETICS & ORTHOTICS4

$0

Covered in-network only

AMBULANCE

Not applicable

$0

CHIROPRACTIC CARE

$12 copay

Deductible and coinsurance