BCBS Pittsfield 2014 Benefit Comparison

MIIA / BCBSMA Active plan offerings (HMO NE and PPO)

BENEFIT

MIIA BCBSMA HMO Blue NE Deductible

(Benchmark) MIIA BCBSMA Deductible BCEP PPO $250/$500/$750

Rates: $539.58 Ind. / $1,415.32 Family Rates: $597.28 Ind. / $1,566.66 Family

In-Network

Deductible $250 Ind. / $750 family In - Network $250 one member /$500 two members/ $750 family for in-network and out of

network combined

Out-of-Pocket Maximum $2,500 per member,$5,000 per family, per plan year $2,500 per member/$5,000 per family for in and out of network combined

medical claims only medical claims only

Lifetime Benefit Maximum None None

INPATIENT HOSPITAL YOU PAY YOU PAY

General Hospital Nothing after Deductible for lower cost Hospitals

$300 co-pay after Deductible for lower cost

Hospitals

(semi-private room $300 co-pay after Deductible for Higher cost Hospitals

$700 co-pay after Deductible for Higher cost

Hospitals

and board and

special services)

Chronic Disease Hospital Nothing after deductible Nothing after deductible

INPATIENT HOSPITAL YOU PAY YOU PAY

Skilled Nursing Facility Nothing after deductible Nothing after deductible

to 45 days per cal. Yr to 45 days per calendar year benefit maximum in & out-of-network combined

Rehabilitation Hospital Nothing after deductible Nothing after deductible

OUTPATIENT GENERAL HOSPITAL YOU PAY YOU PAY

Emergency Room Visits $100 co-pay after deductible $100 per visit after deductible

for Emergency or Accident care


Emergency Room Visits $100 co-pay after deductible $100 per visit after deductible

for Medical Care




Surgery $100 co-pay after deductible $100 co-pay after deductible


Radiation and Chemotherapy Nothing after deductible Nothing after deductible

Diagnostic X-ray and Lab Nothing after deductible Nothing after deductible


MRIs, CT & PET Scans,

$100 co-pay (per category per date of service) after

deductible $100 per category per date of service

after deductible

PHYSICIAN'S OFFICE YOU PAY YOU PAY

Medical Care $20 per visit $20 per visit (no deductible) PCP

$35 per specialist visit $35 per visit (no deductible) Specialists

PHYSICIAN'S OFFICE YOU PAY YOU PAY

Well Child Care Nothing Nothing

Routine GYN Exam Nothing Nothing

1 visit per calendar year 1 visit per calendar year

Routine Vision Exam Nothing Nothing

(1 visit per 24 months) 1 visit per 24 months in & out-of-network combined

Adult Routine Physicals Nothing Nothing

1 visit per 24 months in & out-of-network combined

MENTAL HEALTH YOU PAY YOU PAY

Inpatient admissions in a Nothing after Deductible for lower cost Hospitals

$300 co-pay after Deductible for lower cost

Hospitals

general hospital $300 co-pay after Deductible for Higher cost Hospitals

$700 co-pay after Deductible for Higher cost

Hospitals

MENTAL HEALTH YOU PAY YOU PAY

Inpatient admissions in a $200 per admission after deductible $200 per admission after deductible

mental hospital or



substance abuse facility

Outpatient mental health & $15 co-pay per visit $15 per visit

substance abuse visits

OTHER OUTPATIENT YOU PAY YOU PAY

Physical & Occupational therapy

$20 per visit up to 30 visits per calendar year benefit

maximum for each type of therapy (90)

$20 per visit up to 30 visits per calendar year

benefit maximum for each type of therapy (90)


Visiting Nurse & Nothing after deductible Nothing after deductible

Home Health Care

Durable Medical Nothing after deductible Nothing after deductible

Equipment

Emergency Ambulance Nothing after deductible Nothing after deductible


Chiropractor Visits $20 co-pay per visit (up to 20 visits per cal yr) $20 co-pay per visit (up to 20 visits per cal yr)

visit limit for in and out of network combined


Prescription Drugs $10 for Tier 1 $10 for Tier 1

$25 for Tier 2 $25 for Tier 2


to 30-day supply retail pharmacy to 30-day supply retail pharmacy




to 90-day supply mail service to 90-day supply mail service



MIIA BCBSMA Deductible BCEP PPO $250/$500/$750

Out of Network

$250 one member /$500 two members/ $750 family for in-network and out of

$2,500 per member/$5,000 per family for in and out of network combined

None

YOU PAY

20% coinsurance after deductible


YOU PAY


to 45 days per calendar year benefit maximum in & out-of-network combined


YOU PAY

$100 per visit dafter deductible

YOU PAY

$100 per visit dafter deductible



YOU PAY


YOU PAY



YOU PAY


YOU PAY


YOU PAY







YOU PAY


YOU PAY





YOU PAY


YOU PAY



Nothing after deductible

YOU PAY


YOU PAY


MIIA BCBSMA Sr. offerings

OUTPATIENT GENERAL HOSPITAL YOU PAY

Emergency Room Visits Nothing

for Emergency or Accident

Care

Emergency Room Visits Nothing

for Medical Care

Surgery Nothing

Radiation and Chemotherapy Nothing

Diagnostic X-ray and Lab Nothing

MRIs, CT & PET Scans, and Nothing

Nuclear Cardiac Imaging

Hemodialysis Nothing

PHYSICIAN'S OFFICE YOU PAY

Medical Care Nothing

Routine GYN Exam Nothing

(1 visit every 2 years)

Routine Vision Exam Nothing when approved by Medicare

Only when approved by Medicare

Adult Routine Physicals Medicare provides coverage for one physical exam

when enrolling into Medicare (one yearly no cost) when

approved by Medicare

MENTAL HEALTH YOU PAY

MIIA BCBSMA Sr. offerings 7


Inpatient admissions in a Nothing

general hospital

Inpatient admissions in a Nothing

mental hospital or

substance abuse facility

Outpatient mental health & Nothing

substance abuse visits

OTHER OUTPATIENT YOU PAY

Physical & Occupational Nothing

Therapy

Visiting Nurse & Nothing

Home Health Care

Prosthetic Devices Nothing

Durable Medical Nothing

Equipment

Emergency Ambulance Nothing

Chiropractor Visits Nothing for manual manipulation of the spine to

correct subluxation

Prescription Drugs YOU PAY

$10 for Tier 1

$20 for Tier 2

$35 for Tier 3

to 30-day supply retail pharmacy

$20 for Tier 1

$40 for Tier 2

$70 for Tier 3


** Sr. plans renew Jan. 1 each year due to CMS rules / CMS regulations govern plan benefits and pricing



YOU PAY

$50 per visit

$50 per visit

Nothing

Nothing

Nothing

Nothing

Nothing

YOU PAY

$10 per visit

$10 per visit (1 visit per Cal Yr)

$10 per visit( 1 visit per 24months

$10 per visit

YOU PAY



Nothing

Nothing

Nothing

YOU PAY

$10 per visit

Nothing

$10 per item

$10 per item

Nothing for emergency

$40 copay other when med nec.

$10 per visit

YOU PAY

$10 for Tier 1

$20 for Tier 2

$35 for Tier 3


$20 for Tier 1

$40 for Tier 2

$70 for Tier 3



BCBS Pittsfield 2014 Benefit Comparison

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