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Medical Plans
ASO Plan
| Plan Name: | ASO Plan |
| Description: | Refer to the Summary Plan Description for benefit questions or call First Niagara 518-324-5335 |
| Employee Instructions: | This plan has a PPO network, so coverage is available to any BlueCross BlueShield provider
If any changes are necessary by the member, an application must be completed |
| Start Date - End Date: | 01/01/2014 - 01/01/2015 |
| Group Number: | 00962347 |
| Carrier: | BlueShield of NENY |
| ASO Plan | In-Network | Out-of-Network |
| Deductible | ||
| Individual | $100 | |
| Family | $200 | |
| Co-Insurance | 80% Major Medical | 80% Major Medical |
| Out-of-Pocket Maximum | $500 | $500 |
| Lifetime Maximum | Unlimited | Unlimited |
| Inpatient Services | ||
| Skilled Nursing Facility | 100% | 100% |
| Room and Board | 100% | 100% |
| Surgery | 100% | 100% |
| Lab/X-Rays | 100% | 100% |
| Outpatient Services | ||
| Chemotherapy | 100% | 100% |
| Physical Therapy | 100% | 100% |
| Office Visits | ||
| Routine Eye Exam | No Coverage | No Coverage |
| Routine Hearing Exam | No Coverage | No Coverage |
| Routine Mammogram | 100% | 100% |
| Routine OB/GYN | 100% | 100% |
| Routine Physicals | $50 maximum 50+, member only | $50 maximum 50+, member only |
| Specialists | 80% | 80% |
| Well Baby/Child Care | 100% | 100% |
| Preventive Colonoscopy | 100% | 100% |
| Mental and Nervous | ||
| Inpatient | 100% | 100% |
| Outpatient | 80% | 80% |
| Substance Abuse | 100% | 100% |
| Emergency Services | 100% | 100% |
| Maternity Services | 80% | 80% |
| Diabetic Education | 80% | 80% |
| Chiropractic Services | ||
| Benefit | 80% | 80% |
| Maximum Visits | ||
| Infusion Therapy | 80% | 80% |
| Oral Surgery and Dental Services | No Coverage | No Coverage |
| Vision Coverage | No Coverage | No Coverage |
| Drug Coverage | ||
| Mandatory Mail Order - Maintenance Medications | Yes | No Coverage |
| Brand | $10 | No Coverage |
| Formulary | $10 | No Coverage |
| Generic | $0 | No Coverage |
| Mail Order | $0 / $20 | No Coverage |
| Additional Services | ||
| Ambulance | 80% | 80% |
| Durable Medical Equipment | 80% | 80% |
| Home Health Care | 100% | 100% |
| Hospice Care | 100% | 100% |
| Utilization Review | See SPD | See SPD |
| Exclusions | See SPD | See SPD |
30 days from date of hire for all Union contracts.
POS 298 Class 0003
| Plan Name: | POS 298 Class 0003 |
| Description: | $0 or $15 or $10 PCP Copay
$20 or $15 or $10 Specialist Copay
$5 / $20 / $40 RX copays |
| Employee Instructions: | This plan has a managed network with very little access to Vermont providers |
| Start Date - End Date: | 01/01/2014 - 01/01/2015 |
| Group Number: | 00962347 |
| Carrier: | BlueShield of NENY |
| POS 298 Class 0003 | In-Network | Out-of-Network |
| Deductible | ||
| Individual | $0 | $250 |
| Family | $0 | $500 |
| Co-Insurance | 100% | 80% |
| Out-of-Pocket Maximum | N/A | $5,000 / $10,000 |
| Lifetime Maximum | Unlimited | Unlimited |
| Inpatient Services | ||
| Skilled Nursing Facility | 100% | 80% |
| Lab / X-rays | 100% | 80% |
| Outpatient Services | ||
| Surgery | $20 / $15 / $10 | 80% |
| Chemotherapy | $20 / $15 / $10 | 80% |
| Physical Therapy | $20 / $15 / $10 | 80% |
| Office Visits | ||
| Routine Eye Exam | $20 / $15 / $10 | No Coverage |
| Routine Hearing Exam | No Coverage | No Coverage |
| Routine Mammogram | 100% | 80% |
| Routine OB/GYN | $20 / $15 / $10 | 80% |
| Routine Physicals | $0 / $5 / $10 | No Coverage |
| Specialists | $20 / $15 / $10 | 80% |
| Well Baby / Child Care | 100% | 80% |
| Mental and Nervous | ||
| Inpatient | 100% | 80% |
| Outpatient | $20 / $15 / $10 | 80% |
| Substance Abuse | $20 / $15 / $10 | 80% |
| Emergency Services | $35 Copay | $35 Copay |
| Maternity Services | $0 / $5 / $10 | 80% |
| Chiropractic Services | ||
| Benefit | $10 Copay | 80% |
| Maximum Visits | Prior Authorization Required | Prior Authorization Required |
| Vision and Dental Coverage | ||
| Annual Vision Exam | $20 / $15 / $10 | No Coverage |
| Annual Dental - Cleaning and Exam Only | $20 / $15 / $10 | No Coverage |
| Drug Coverage | ||
| Allergy Serum / Injections | $20 / $15 / $10 | 80% |
| Brand | $20 | No Coverage |
| Formulary | $40 | No Coverage |
| Generic | $5 | No Coverage |
| Mail Order | 3 copays for 90 days | |
| Additional Services | ||
| Ambulance | 100% | 80% |
| Durable Medical Equipment | 80% | 50% |
| Home Health Care | 100% | 80% |
| Hospice Care | 100% | 80% |
| Utilization Review | See SPD | See SPD |
| Exclusions | See SPD | See SPD |
30 days from date of hire for all Unions.
| Title / Department: | Customer Service |
| Address: | 30 Century Hill Drive |
| City: | Latham |
| State: | NY |
| ZIP / Postal Code | 12110 |
| Phone: | 888-840-6322 |
POS 298 Class 0005
| Plan Name: | POS 298 Class 0005 |
| Description: | $0 or $15 or $10 PCP Copay
$20 or $15 or $10 Specialist Copay
$5 / $10 / $25 RX copays |
| Employee Instructions: | This plan has a managed network with very little access to Vermont providers |
| Start date - End date: | 01/01/2014 - 01/01/2015 |
| Group Number: | 00962347 |
| Carrier: | BlueShield of NENY |
| POS 298 Class 005 | In-Network | Out-of-Network |
| Deductible | ||
| Individual | $0 | $250 |
| Family | $0 | $500 |
| Co-Insurance | 100% | 80% |
| Out-of-Pocket Maximum | N/A | $5,000 / $10,000 |
| Lifetime Maximum | Unlimited | Unlimited |
| Inpatient Services | ||
| Skilled Nursing Facility | 100% | 80% |
| Lab / X-Rays | 100% | 80% |
| Outpatient Services | ||
| Surgery | $20 / $15 / $10 | 80% |
| Chemotherapy | $20 / $15 / $10 | 80% |
| Physical Therapy | $20 / $15 / $10 | 80% |
| Office Visits | ||
| Routine Eye Exam | $20 / $15 / $10 | No Coverage |
| Routine Hearing Exam | No Coverage | No Coverage |
| Routine Mammogram | 100% | 80% |
| Routine OB/GYN | $20 / $15 / $10 | 80% |
| Routine Physicals | $0 / $5 / $10 | No Coverage |
| Specialists | $20 / $15 / $10 | 80% |
| Well Baby / Child Care | 100% | 80% |
| Mental and Nervous | ||
| Inpatient | 100% | 80% |
| Outpatient | $20 / $15 / $10 | 80% |
| Substance Abuse | $20 / $15 / $10 | 80% |
| Emergency Services | $35 Copay | $35 Copay |
| Maternity Services | $0 / $5 / $10 | 80% |
| Chiropractic Services | ||
| Benefit | $10 Copay | 80% |
| Maximum Visits | Prior Authorization Required | Prior Authorization Required |
| Vision and Dental Coverage | ||
| Annual Vision Exam | $20 / $15 / $10 | No Coverage |
| Annual Dental - Cleaning and Exam Only | $20 / $15 / $10 | No Coverage |
| Drug Coverage | ||
| Allergy Serum / Injections | $20 / $15 / $10 | 80% |
| Brand | $10 | No Coverage |
| Formulary | $25 | No Coverage |
| Generic | $5 | No Coverage |
| Mail Order | 3 Copays for 90 days | |
| Additional Services | ||
| Ambulance | 100% | 100% |
| Durable Medical Equipment | 80% | 50% |
| Home Health Care | 100% | 80% |
| Hospice Care | 100% | 80% |
| Utilization Review | See SPD | See SPD |
| Exclusions | See SPD | See SPD |
30 days from date of hire for all Unions.
| Title / Department: | Customer Service |
| Address: | 31 Century Hill Drive |
| City: | Latham |
| State: | NY |
| ZIP / Postal Code: | 12110 |
| Phone: | 888-840-6322 |
POS 298 Class 0004
| Plan Name: | POS 298 Class 0004 |
| Description: | $20 PCP and Specialist Copay
$10 / $20 / $40 RX copays |
| Employee Instructions: | This plan has a managed network with very little access to Vermont providers |
| Start Date - End Date: | 01/01/2014 - 01/01/2015 |
| Group Number: | 00962347 |
| Carrier: | BlueShield of NENY |
| POS 298 Class 0004 | In-Network | Out-of-Network |
| Deductible | ||
| Individual | $0 | $500 |
| Family | $0 | $1,000 |
| Co-Insurance | 100% | 75% |
| Out-of-Pocket Maximum | N/A | Unlimited |
| Lifetime Maximum | Unlimited | Unlimited |
| Inpatient Services | ||
| Skilled Nursing Facility | 100% | 75% |
| Lab / X-Rays | 100% | 75% |
| Outpatient Services | ||
| Surgery | $75 | 75% |
| Chemotherapy | $20 | 75% |
| Physical Therapy | $20 | 75% |
| Office Visits | ||
| Routine Eye Exam | $20 | No Coverage |
| Routine Hearing Exam | No Coverage | No Coverage |
| Routine Mammogram | 100% | 75% |
| Routine OB/GYN | $20 | 75% |
| Routine Physicals | $20 | No Coverage |
| Specialists | $20 | 75% |
| Well Baby / Child Care | 100% | 75% |
| Mental and Nervous | ||
| Inpatient | 100% | 75% |
| Outpatient | $20 | 75% |
| Substance Abuse | $20 | 75% |
| Emergency Services | $50 Copay | $50 Copay |
| Maternity Services | $20 | 75% |
| Chiropractic Services | ||
| Benefit | $10 Copay | 75% |
| Maximum Visits | Prior Authorization Required | Prior Authorization Required |
| Vision and Dental Coverage | ||
| Annual Vision Exam | $20 | No Coverage |
| Annual Dental - Cleaning and Exam Only | $20 | No Coverage |
| Drug Coverage | ||
| Allergy Serum / Injections | $20 | 75% |
| Brand | $20 | No Coverage |
| Formulary | $40 | No Coverage |
| Generic | $10 | No Coverage |
| Mail Order | 3 Copays for 90 days | |
| Additional Services | ||
| Ambulance | 100% | 100% |
| Durable Medical Equipment | 80% | 50% |
| Home Health Care | 100% | 75% |
| Hospice Care | 100% | 75% |
| Utilization Review | See SPD | See SPD |
| Exclusions | See SPD | See SPD |
30 days from date of hire for all Unions.
| Title / Department: | Customer Service |
| Address: | 31 Century Hill Drive |
| City: | Latham |
| State: | NY |
| ZIP / Postal Code: | 12110 |
| Phone: | 888-840-6322 |
POS 298 Class 0007
| Plan Name: | POS 298 Class 0007 |
| Description: | $20 PCP and Specialist Copay
$5 / $10 / $25 RX copays |
| Employee Instructions: | This plan has a managed network with very little access to Vermont providers |
| Start Date - End Date: | 01/01/2014 - 01/01/2015 |
| Group Number: | 00962347 |
| Carrier: | BlueShield of NENY |
| POS 298 Class 0007 | In-Network | Out-of-Network |
| Deductible | ||
| Individual | $0 | $500 |
| Family | $0 | $1,000 |
| Co-Insurance | 100% | 75% |
| Out-of-Pocket Maximum | N/A | Unlimited |
| Lifetime Maximum | Unlimited | Unlimited |
| Inpatient Services | ||
| Skilled Nursing Facility | 100% | 75% |
| Lab / X-Rays | 100% | 75% |
| Outpatient Services | ||
| Surgery | $75 | 75% |
| Chemotherapy | $20 | 75% |
| Physical Therapy | $20 | 75% |
| Office Visits | ||
| Routine Eye Exam | $20 | No Coverage |
| Routine Hearing Exam | No Coverage | No Coverage |
| Routine Mammogram | 100% | 75% |
| Routine OB/GYN | $20 | 75% |
| Routine Physicals | $20 | No Coverage |
| Specialists | $20 | 75% |
| Well Baby / Child Care | 100% | 75% |
| Mental and Nervous | ||
| Inpatient | 100% | 75% |
| Outpatient | $20 | 75% |
| Substance Abuse | $20 | 75% |
| Emergency Services | $50 Copay | $50 Copay |
| Maternity Services | $20 | 75% |
| Chiropractic Services | ||
| Benefit | $10 Copay | 75% |
| Maximum Visits | Prior Authorization Required | Prior Authorization Required |
| Vision and Dental Coverage | ||
| Annual Vision Exam | $20 | No Coverage |
| Annual Dental - Cleaning and Exam Only | $20 | No Coverage |
| Drug Coverage | ||
| Allergy Serum / Injections | $20 | 75% |
| Brand | $10 | No Coverage |
| Formulary | $25 | No Coverage |
| Generic | $5 | No Coverage |
| Mail Order | 3 Copays for 90 days | |
| Additional Services | ||
| Ambulance | 100% | 100% |
| Durable Medical Equipment | 80% | 50% |
| Home Health Care | 100% | 75% |
| Hospice Care | 100% | 75% |
| Utilization Review | See SPD | See SPD |
| Exclusions | See SPD | See SPD |
30 days from date of hire for all Unions.
| Title / Department: | Customer Service |
| Address: | 31 Century Hill Drive |
| City: | Latham |
| State: | NY |
| ZIP / Postal Code | 12110 |
| Phone: | 888-840-6322 |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.