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.