LIFE HAS A PLAN - Hamilton College

A nonprofit independent licensee of the Blue Cross Blue Shield Association
LIFE HAS A PLAN
Your Benefit
Plan Details
Excellus BlueCross BlueShield makes finding the
information and support you need
easier—resources, savings, and tools are available
online 24/7.
•
Find a doctor or specialist online while you’re home
or far away.
•
Get instant access to StepUp, our FREE fitness and
nutrition program.
•
Research over 6,000 health topics.
•
Get great member discounts and valuable
information you can use all year long with
Blue365®
Welcome
With Excellus BlueCross BlueShield, you get what you
expect from Blue plus a whole lot more such as:
excellusbcbs.com
•
More doctors, specialists, and hospitals to
choose from
•
Exclusive discounts on health-related products
and services with Blue365®
•
Free fitness and nutrition program with StepUp
•
Answers to your health questions online
•
Local customer service
In this booklet you will find:
•
A chart that summarizes this plan’s unique benefits
and coverage*
•
A glossary of terms to help you understand your
coverage and options
We have many valuable benefits and we provide a
tremendous amount of choice. Whichever plan you
pick, we're ready to meet your health care needs.
Visit us at excellusbcbs.com
*This benefit summary is not a contract or binding agreement;
it is a summary of benefits and services.
Privacy Policy Notice. We know how important your privacy is and we’re committed to
protecting it. Our policies and practices regarding the collection, use, and disclosure of
personal health information are available at excellusbcbs.com and Member Services.
EBCBS - 08/10
4747-10M
Hamilton College
PPO
Plan Features
Primary Care Physician (PCP)
Referrals
Out of network benefits
Domestic Partner
Coverage Period
Office visit copay (Primary Care Physician)
Office visit copay (Specialist)
Coinsurance
Deductible
Out of pocket maximum
Lifetime maximum
Not Required
Not Required
Covered
Covered
01/01/14-12/31/14
$25
$40
In-network: 10% Out-of-network: 30% except where noted
In-network: $250/$750. Out of Network $1,000/$2,500
In-network: $1,500/$4,500; Out of Network: $3,000/$7,500
None
Questions? Call member services at ,
Call our TTYphone at 1 (877) 398-2282
1425
Excellus BluePPO benefits
1
Prepared 11/4/2013 for Hamilton College
Type of Care/Plan Benefits
Plan features
• Primary Care Physician (PCP)
• Referrals
• Out of network benefits
• Out of area benefits
• Student/Dependent coverage
• Domestic partner
• Coverage Period
Plan cost-sharing highlights
• Office visit copay (Primary Care
Physician)
• Office visit copay (Specialist)
• Coinsurance
In-Network
•
Not required
Not required
Covered
Coverage provided worldwide through the BlueCard program.
Qualified dependents and students are covered to age 26.
Covered
January 1st - December 31st
•
$25 copay
•
$40 copay
In-network: 10% except where noted. Out-of-network: 30% except where
noted.
In-network: $250 individual /$750 family. Out of Network $1,000 individual
/$2,500 family
In-network OOP Max: $1500 individual/4500 family have deductible,
coinsurance and copays apply. Out-of-Network OOP Max: $3000 individual
/$7500 family. In and Out of Network will be separate OOP Max limits
None
•
•
•
•
•
•
•
•
Deductible
•
•
Out of pocket maximum
•
•
Lifetime maximum
•
type of care/plan benefits
Out Of Network
In-Network
Out Of Network
Wellness Incentive
• Stay healthy with great programs and
incentives!
•
Blue365 - Take advantage of exclusive
discounts on health and wellness
products and services, including fitness,
exercise, nutrition, elective procedures
and hearing aids.
•
Blue365 - Take advantage of exclusive
discounts on health and wellness
products and services, including fitness,
exercise, nutrition, elective procedures
and hearing aids.
Preventive Health Care Services
• Well child visits
• Adult routine physical exams
•
Covered in full
Covered in full for 1 exam per year
according to national guidelines
•
•
Covered in full
Covered at 70%, subject to the
deductible for one routine exam per
year
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
•
•
Adult immunizations
•
Covered in full
•
•
Mammography
•
Covered in full
•
•
Pap smear
•
Covered in full
•
•
Routine GYN exam
•
Covered in full, including lab
•
•
Prostate cancer screening
•
Covered in full
•
•
Colonoscopy
•
Covered in full
•
Physician Office Services
continued
pg. 1
Excellus BluePPO benefits
1
Prepared 11/4/2013 for Hamilton College
Type of Care/Plan Benefits
In-Network
•
Diagnostic office visits
•
•
Diagnostic x-rays
•
•
Diagnostic laboratory and pathology
•
Out Of Network
$25 copay per PCP visit/ $40 copay per
Specialist visit
$40 copay. Precertification applies to
MRI, PET and CAT scans.
•
•
Covered in full
•
Allergy tests
•
$40 copay per visit
•
•
Allergy injections
•
Covered in full
•
•
Chemotherapy
•
•
•
Radiation therapy
•
Covered at 90%, subject to the
deductible
Covered at 90%, subject to the
deductible
•
Covered in full
•
•
Facility: Covered at 90%, subject to the
deductible. Physician: Covered in full
Covered at 90%
•
•
Covered through Express Scripts. Also
diabetic supplies and insulin covered
through Express Scripts.
•
Not covered
•
Covered at 90%, subject to the
deductible per admission for unlimited
days. Precertification applies.
Covered at 90% subject to the
deductible.
Covered at 90%, subject to the
deductible.
Covered at 90%, subject to the
deductible.
Covered at 90%, subject to the
deductible, 60 days per calendar year
•
Covered at 70%, subject to the
deductible. Precertification applies.
•
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Cover at 70%, subject to the
deductible, 60 days per calendar year.
$200 copay per visit, unless admitted
within 24 hours
$25 copay per visit
•
$200 copay
$200 copay
•
Maternity Services
• Prenatal and postpartum care
•
•
Hospital care for mom (including
delivery)
Newborn nursery care
Prescription Drug
• Short-term and maintenance drugs are
covered up to a 30-day supply at
participating retail pharmacies; 90-day
supply (subject to two copays per
90-day supply) is available through
PrimeMail mail order pharmacy.
Contraceptives included.
Inpatient Hospital Benefits
• Hospital benefits
•
•
Physician visits in the hospital
•
•
Surgery
•
•
Anesthesia
•
•
Inpatient Physical Rehabilitation
•
Emergency Care
• Emergency room care
•
•
•
Freestanding urgent care center
Ambulance
Prehospital Emergency
Services/Transportation
continued
•
•
•
•
•
•
•
•
•
•
•
•
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible. Precertification applies to
MRI, PET and CAT scans.
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
$200 copay per visit, unless admitted
within 24 hours
Covered at 70%, subject to the
deductible
$200 copay
$200 copay
pg. 2
Excellus BluePPO benefits
1
Prepared 11/4/2013 for Hamilton College
Type of Care/Plan Benefits
Outpatient Hospital Benefits
• Diagnostic x-rays
In-Network
Out Of Network
•
$40 copay per visit. Precertification
applies to MRI, PET and CAT scans.
•
Covered at 70%, subject to the
deductible. Precertification applies to
MRI, PET and CAT scans
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
•
Diagnostic laboratory and pathology
•
Covered in full
•
•
Surgical care
•
•
•
Chemotherapy
•
•
Radiation therapy
•
Covered at 90%, subject to the
deductible
Covered at 90%, subject to the
deductible
Covered at 90%, subject to the
deductible
Covered at 90%, subject to the
deductible per admission for unlimited
days. Precertification applies.
$40 copay. Services can be provided in
an outpatient facility or in a provider
office.
•
Covered at 70%, subject to the
deductible. Precertification applies.
•
•
Covered at 70%, subject to the
deductible. Services can be provided in
an outpatient facility or in a provider
office.
Covered at 70%, subject to the
deductible. Precertification applies.
•
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible for up to a 30 day supply
Covered at 70%, subject to the
deductible for up to 60 days per year.
Precertification applies.
Covered at 75%, subject to a $50
deductible, unlimited days per calendar
year. Precertification applies.
Covered at 70%, subject to the
deductible for unlimited visits per year
Covered at 70%, subject to the
deductible for a combined total of 45
visits per year for physical, speech,
occupational and respiratory therapy
Covered at 70%, subject to the
deductible. Precertification applies.
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible
Covered at 70%, subject to the
deductible for accidental injury to
sound, natural teeth and for care due
to congenital disease or anomaly
Mental Health and Chemical
Dependence
• Inpatient mental health care
•
•
•
•
Outpatient mental health care
•
•
Inpatient chemical dependence
•
•
Outpatient chemical dependence
•
Covered at 90%, subject to the
deductible per admission for unlimited
days. Precertification applies
$40 copay per visit
•
$25 copay for up to a 30 day supply
•
Covered at 90%, subject to the
decuctible- per admission for up to 60
days per year. Precertification applies.
Covered at 90% subject to $50
deductible, unlimited days per calendar
year. Precertification applies.
Covered in full for unlimited days
•
•
Other Services
• Diabetic insulin and supplies
•
Skilled nursing facility
•
•
Home care
•
•
Hospice
•
•
Outpatient therapy
•
•
Durable medical equipment
•
•
External prosthetics
•
$40 copay for up to a combined total
of 45 visits per year for physical,
speech, respiratory and occupational
therapy
Covered at 80%. Precertification
applies.
Covered at 80%
•
Chiropractic
•
$40 copay per visit
•
•
Dental
•
$20 copay for accidental injury to
sound, natural teeth and for care due
to congenital disease or anomaly
•
•
•
•
•
This is not a contract. It is intended to highlight the coverage of this program. Benefits are determined by the terms of the contract. All benefits are subject to medical necessity. These benefits should not be
interpreted as pre-approval of services. Certain services may be subject to additional requirements described in the member’s insurance policy. Payment of claims related to these benefits are subject to the
member’s eligibility on the date of service and the resolution of any other outstanding claims. The member is responsible for payment of a copay, deductible, coinsurance or any combination based on plan design.
Preventive Services coverage required by the Federal Patient Protection and Affordable Care Act may not be quoted herein. Please refer to the Services Task Force list of items and services rated “A” or “B” that are
covered pursuant to the Federal Protection and Affordable Care Act requirements. Benefits herein are subject to change as a result of efforts to implement federal health care reform and mental health and
substance abuse care parity initiative. There may be additional coverage for biologically-based mental illness and for children with serious emotional disturbances as defined by Timothy’s Law.
pg. 3
Find a Doctor or Specialist
Excellus BlueCross BlueShield is part of a network of BlueCross BlueShield Plans that make up the
largest group of Participation Doctors and Specialists in the world. With that you get cost effective
quality health care whenever you need it.
Our online provider directory
makes it easy to search for providers by:
•Name
• Zip code
•Gender
• Languages spoken
• Accepting new patients
• Hospital affiliation
Results include:
• Office hours
•Locations
• Phone numbers
• Map & Directions
• Handicap Accessibility
Just look over our alphabetical
listing online at ExcellusBCBS.
com/FindProvider
ExcellusBCBS.com/FindProvider
7002-13
Find a Doctor 09/13
Welcome to Blue365
Where taking care of yourself is an everyday thing.
Take advantage of healthy deals and discounts* on fitness, healthy eating, personal care and more
that you can use all year long. Explore all the healthy choices at ExcellusBCBS.com/Blue365
Blue365® is here for you.
Blue365
We understand that helping you live a
healthy life means more than regular
doctor visits - it’s helping you find time
for the things that matter most.
Blue365 includes offers from selected
companies based on feedback from
Blue365 members and independent
researchers on the Blue365 team in
four main categories.
That’s why we created Blue365, an
online destination featuring healthy
deals and discounts exclusively for our
members. These “Blue365 Deals” which
complement your health care coverage,
can help you maintain a healthy lifestyle,
while spending less at some of your
favorite Blue365 vendors nationwide.
Fitness: Save on membership, monthly
fees and other services at Healthways,
Snap Fitness™, Reebok®, and Polar®.
Because of the Blues’ buying power,
Blue365 can offer access to great savings
on a wide range of exciting health and
wellness products and experiences.
Blue365 makes it easy for you to find
out about weekly”Featured Deals” by
sending the news right to your email.
Our email service is free to members of
participating local Blue Companies.
All you have to do is register on the
website, and you are all set to enjoy
our great health and wellness deals.
You’ll see weekly “Featured Deals”
and long term “Ongoing Deals” on
health products, along with discounts
on health and fitness clubs, weight-loss
programs, healthy travel experiences
and so much more.
*Discounts are available through independent companies that do not provide Blue Cross and/or Blue Shield products or services
and are solely responsible for the services provided. See our website for more information at: www.excellusbcbs.com/Blue365.
The content, tools and discounted offers available through Blue365 are subject to change. Please visit excellusbcbs.com/Blue365
for the most current program details.
7002-13 EX Blue365 - 10/22_R
Healthy Eating: Save on programs, products and consultations at Jenny Craig®, Dole® and Nutrisystems®.
Living: Save on services from
H&R Block®.
Personal Care: Save on products and services from TruHearing,
Beltone®, LasikPlus®, Davis Vision®
and QualSight Lasik®.
Coverage wherever you go with
Excellus BlueCross BlueShield
All you have to do is show your ID card to any BlueCross BlueShield participating hospital
or doctor anywhere in the country and you’re covered. At the special negotiated rate, with
no paperwork. That’s the BlueCard® program.
BlueCard brings you:
•Freedom to choose any provider (85% of the hospitals
and physicians in the U.S.)
•BlueCross BlueShield provider
network discounts
•Customer service online and
toll-free
•No claim forms with network
providers
•An ID card recognized
worldwide while traveling
•Coverage for kids who are
away from home
It’s so easy to use.
Choose the physician, specialist,
or hospital you want to use by
calling 1 (800) 810-BLUE (2583)
or visiting ExcellusBCBS.com.
Then just show your BlueCross
BlueShield ID card when you
arrive.
To make it even easier, network
providers bill us directly. You
can also see providers outside
the network. Your share of costs
will probably be higher, but you
have the freedom to choose.
Two ways your coverage
travels with you.
As a BlueCross BlueShield
member, you have access to
health benefits across the
country whether you’re taking a
quick trip or staying long term.
Here’s how it works:
•If you’re traveling, the BlueCard
program gives you access to
doctors and hospitals almost
everywhere. In an emergency,
you should go directly to the
nearest emergency room. For
all other types of needed care,
just call your Primary Care
Physician (PCP) back at home
for instruction on what to do.
•If you are away from home for
more than 90 days, you can
use the Guest Membership
benefit through Away
From Home Care®. Guest
Membership is a temporary
enrollment that enables
members who are living
away from home to receive
benefits including individual,
routine and preventive
services. It provides you and
your family with the peace
of mind of accessible health
care. Perfect for any covered
family member attending
school out of state, located in
a different service area on a
long-term work assignment or
retirees with dual residence
(excludes Medicare). For
eligibility information and
specific locations where the
Guest Membership benefit is
available, please contact our
Customer Service Department.
Learn more about the
BlueCard program
You can call toll-free, within the
United States, at 1 (800) 810-BLUE
or, for international calls,
1 (804) 673-1177, day or night,
and get information on doctors
and hospitals around the world.
Visit us online at ExcellusBCBS.com.
BlueCard - 12/07
The support you need
whenever you need it.
Health Coaching – 24/7
The Excellus BlueCross BlueShield Health Coaching program can
provide you with answers to virtually any health care question you
might have 24/7. From reliable information regarding treatment options, to help thinking through a health care decision, to
assistance managing a current condition. They’re available to
you anytime.
What a Health Coach can do for you:
• Develop a personalized wellness plan based on your needs and your budget
• Coach and motivate you to help change unhealthy behaviors
• Research providers and programs that fit your needs
• Provide preventive health information for developing healthy habits
• Help manage chronic conditions
Call a Health Coach when you need:
• Caring support from someone who has the time to listen to you and answer your questions
• Assistance managing chronic conditions such as asthma, diabetes and heart disease
• Information to prepare for medical tests, procedures and surgery
• In-depth information on treatment options for complex medical issues
• Help making the most of your health care provider visits
• Educational materials and videos sent to your home at no charge
• Information on symptoms being experienced
• Tips for communicating concerns with a doctor
Can’t get to a phone?
• You can also contact a Health Coach online, through our Health Coaching Dialog Center.
• You get the support you need when and how you want it.
Even more information available online
If you’re looking for credible information on conditions, treatments, procedures, preventive care,
medications and more, you’ll find it online with our Healthwise® Knowledgebase. It connects you to more
than 6,000 health topics with just a few mouse-clicks.
Continued
B-3531 07/11
iService available to eligible Excellus BlueCross BlueShield members only.
Health Coaches do not offer medical advice, nor do they practice medicine or nursing. They act soley
as a source for support and education. Always speak with a doctor before taking any kind of medical
action as the information provided by our health coaches is not intended to replace the advice of a
medical professional.
Excellus BlueCross BlueShield contracts with the federal government and is a Medicare Advantage
Organization with a Medicare contract.
The benefit information herein is a brief summary, not a comprehensive description of benefits. For more
information contact the plan. Benefits may change on January 1, 2012.
T h e i m p o r t a n c e o f p r e v e n t i o n .
Preventive care helps reduce the risks and costs of illness. Just as your
health insurance is there if you need it, this helpful information is here
for you every day. Here are the recommended schedules for exams,
screenings, and immunizations. You can keep track of your schedules
and your family’s at My Health Connection on our web site.
Recommended immunization schedule for persons aged 0 through 6 years
Birth
Hepatitis B
1 mo.
HepB
2 mos.
4 mos.
6 mos.
RV
RV
RV
12 mos.
HepB
Rotavirus
15 mos.
18 mos.
19-23 mos.
2–3 yrs.
4–6 yrs.
HepB
Diphtheria, Tetanus, Pertussis
DTaP
DTaP
DTaP
Haemophilus influenza Type b
Hib
Hib
Hib
Hib
DTaP
Pneumococcal
PCV
PCV
PCV
PCV
Inactivated Polio
IPV
IPV
DTaP
PPSV
IPV
Influenza
IPV
Influenza (yearly)
Measles, Mumps, Rubella
Varicella
MMR
MMR
Varicella
Varicella
Hepatitis A
HepA (2 doses)
HepA series
Meningococcal
MCV
Recommended immunization
schedule for persons
aged 7 through 18 years
7–10 yrs.
Diphtheria, Tetanus, Pertussis
Human Papillomavirus
Meningococcal
Influenza
MCV
11–12 yrs.
Adults need regularly scheduled exams as well. As you can see
on the chart below, there are many preventive screens that should be
performed to help detect disease early and help you stay healthy.
13–18 yrs.
TdaP
TdaP
HPV (3 doses)
HPV Series
MCV
MCV
Influenza (yearly)
Pneumococcal
PPSV
How often you have the following screenings depends on your age,
your health, and things that increase your risk for specific diseases.
Screenings that may be done at your routine checkups include:
• Alcohol abuse (misuse)
• Hearing
• Blood pressure
• HIV
• Prostate cancer for men
Hepatitis A
HepA series
• Breast cancer for women
Hepatitis B
HepB series
• Cervical cancer for women
• Sexually transmitted disease
• Cholesterol
• Skin cancer
• Colorectal cancer
• Testicular cancer for men
• Coronary artery disease
• Thyroid disease
• Depression
• Tuberculosis
• Diabetes type 2
• Vision and glaucoma
Inactivated Poliovirus
Measles, Mumps, Rubella
Varicella
IPV series
MMR series
Varicella series
Range of recommended ages for all children except certain high-risk groups
Range of recommended ages catch-up vaccination
Range of recommended ages for certain high-risk groups
This schedule indicates the recommended ages for administration of
currently licensed childhood vaccines, as of December 15, 2010. If doses
are skipped, they should be made up at subsequent visits when possible.
Approved by the Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention, the American Academy of
Pediatrics, and the American Academy of Family Physicians.
Children should see their doctor regularly
• to become comfortable with the people and the
office
• Gestational diabetes for
women
Monitor your weight, and see your doctor if you suddenly or
consistently gain or lose weight.
For more information visit ExcellusBCBS.com
• to receive the immunizations shown above.
• to have their growth and development
monitored.
• to address any questions or concerns you might
have about your child.
Preventive 09/11
Recommended Adult Immunization Schedule
by vaccine and age group
50-59 years
Influenza
Tetanus, diphtheria, pertussis
(Td/Tdap)
60-64 years
>65 years
1 dose annually
Subsititute 1-time dose of Tdap for td
booster;then boost with Td every 10 yrs
Varicella
Td booster every 10 yrs
2 doses
Zoster
Measles, Mumps, Rubella (MMR)
Pneumococcal (polysaccharide)
Meningococcal
1 dose
1 or 2 dose
1 dose
1 or more dose
1 dose
1 or more doses
Hepatitis A
2 doses
Hepatitis B
3 doses
Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting
forms and instructions on filing a VAERS report are available at http://www.vaers.hhs.gov or by telephone, 800-822-7967.
Information on how to file a Vaccine Injury Compensation Program claim is available at http://www.hrsa.gov/vaccinecompensation or by telephone, 800-338-2382. Information about filing a claim for vaccine injury is avail- able through the U.S.
Court of Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400.
Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination
also is available at http://www.cdc.gov/vaccines or from the CDC-INFO Contact Center at 800-CDC-INFO (800-232-4636) in
English and Spanish, 24 hours a day, 7 days a week.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S.
Department of Health and Human Services.
The recommendations in this schedule were approved by the Centers for Disease Control and Prevention’s (CDC) Advisory
Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), the American College of
Obstetricians and Gynecologists (ACOG), and the American College of Physicians (ACP).