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BLUE CARD 350 |
Plan Description
HSA 6750 |
2500 |
350 |
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| Rx Formulary | Rx Formulary | Rx Formulary | Rx Formulary |
| Rx Search | Rx Search (Members must have ID Card to Create Account to view.) |
Rx Search (Members must have ID Card to Create Account to view.) |
Rx Search (Members must have ID Card to Create Account to view.) |
| SBC |  |
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| Lifestyle Benefit |  |
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| Enrollment Deadline | 18th of month Prior to Effective date | 18th of month Prior to Effective date | 18th of month Prior to Effective date |
| Plan Availability | All 50 States | All 50 States | All 50 States |
| Referrals | No Referrals Required | No Referrals Required | No Referrals Required |
| Preventative Care | In-Net: 100% Out-Net: Not Covered |
In-Net: 100% Out-Net: Deductible & Co-Insurance |
In-Net: 100% Out-Net: Deductible & Co-Insurance |
| Preventative Services | 100% Coverage for Mandated Preventative Services Preventative Services for Adults Preventative Services for Woman Preventative Services for Children |
100% Coverage for Mandated Preventative Services Preventative Services for Adults Preventative Services for Woman Preventative Services for Children |
100% Coverage for Mandated Preventative Services Preventative Services for Adults Preventative Services for Woman Preventative Services for Children |
| Deductible | In-Net: $6,750 Single / $13,500 Family | In-Net: $2,500 Single / $5,000 Family | In-Net: $350 Single / $700 Family |
| Out-Net: $10,000 Single / $20,000 Family | Out-Net: $6,750 Single / $13,500 Family | Out-Net: $700 Single / $1,400 Family | |
| Co-Insurance | In-Net: Subject to Deductible no copay Out-Net: 50% After Deductible |
In-Net: 30% After Deductible Out-Net: 50% After Deductible |
In-Net: 30% After Deductible Out-Net: 50% After Deductible |
| Out-Of-Pocket Max | In-Net: $6,750 Single / $13,500 Family Out-Net: $20,000 Single / $40,000 Family |
In-Net: $8,150 Single / $ 16,300 Family Out-Net: Unlimited Single / Unlimited Family |
In-Net: $8,150 Single / $ 16,300 Family Out-Net: Unlimited Single / Unlimited Family |
| Office copayments | In-Net: Subject to Deductible no copay | $40 copay: Deductible does not apply $60 copay: Deductible does not apply |
$25 copay: Deductible does not apply $35 copay: Deductible does not apply |
| Out-Net: Deductible & Co-Insurance | Out-Net: Deductible & Co-Insurance | Out-Net: Deductible & Co-Insurance | |
| Out-Patient Mental Health | In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
In-Net: $35 copay Out-Net: Deductible & Co-Insurance |
Chiropractic |
In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: $60 copay Out-Net: Deductible & Co-Insurance |
In-Net: $35 copay Out-Net: Deductible & Co-Insurance |
| Rehabiltation Services Out-Patient: 30 visits per cal. year In-Patient: 120 visits per cal. year |
In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
| Hospital (In-Patient) | In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
| Hospital (Out-Patient) | In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
| Childbirth/Delivery Facility | In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
Prescription
Benefits |
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| Generic: Subject to Deductible No copay |
Generic: $0 | Generic: $0 | |
| Brand preferred: Subject to Deductible No copay |
Brand preferred: 25% |
Brand preferred: 25% |
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| Non-Preferred: Subject to Deductible No copay |
Non-Preferred: 50% | Non-Preferred: 50% | |
| Not Subject to Deductible | Not Subject to Deductible | ||
| Emergency Medical Transportation (No coverage for Air Transport) |
In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
| Emergency Room | In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
| Diagnostic Testing (X-Ray, Bloodwork) |
In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: No Charge Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
| Advanced Imaging | In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
| Urgent Care | In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net:
$40 Copay Not subject to deductible Out-Net: Deductible & Co-Insurance |
In-Net:
$25 Copay Not subject to deductible Out-Net: Deductible & Co-Insurance |
| Child Eye Exam & Dental check-up |
In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net:
No Charge Out-Net: Not Covered |
In-Net:
No Charge Out-Net: Not Covered |
| Durable Medical | In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
| Home Health Care | In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
| Hospital Out-patient Facility | In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
| Physician and Surgeon Fees | In-Net: Subject to Deductible no copay Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
In-Net: Deductible & Co-Insurance Out-Net: Deductible & Co-Insurance |
| Union death Benefit (Member Only) |
$5,000 | $5,000 | $5,000 |
| Out-of-Network Payment Type | 125% Medicare | 125% Medicare | 125% Medicare |
Motor vehicle injuries, any and all related charges, including deductible arising from or related to a motor vehicle accident. A Motor Vehicle is not limited to an automobile, truck or van. It includes motorcycles, mopeds, all-terrain vehicles, snowmobiles, and other recreational vehicles (including motorized scooters, etc.). Please note, when you purchase or renew your automobile insurance you have the option of opting out of personal injury protection ("PIP") insurance. We urge you not to exercise that option. If you do, you will have no hospitalization or medical coverage if you or your dependent is involved in a motor vehicle accident. (Initial $25,000 of medical charges resulting from a motor vehicle accident.)
• Diagnostic Testing: Not covered at a hospital unless the test cannot be performed at a diagnostic center or participating labs.
• Advance Diagnostic Testing: Not covered at a hospital unless the test cannot be performed at a diagnostic center or participating labs.
• Emergency Medical Transportation: No coverage for Air Transport.
In addition to any limits described under the sections which describe the benefits, there are specific limitations and exclusions with regard to all benefits. No benefits are payable for:
• Air Ambulance and Air Transportation
• Abortion or maternity for dependents;
• Elective abortion, except for an abortion when the eligible female's life would be endangered if the fetus was to be carried to term;
• Acupuncture;
• Adoption expenses;
• Services provided for ambulette service;
• Artificial mechanical organs;
• Bio feedback;
• CAT and/or MRI scans when ordered by a Chiropractor;
• Clinic visits;
• Cochlear implants or hearing aids;
• Counseling: Family, Marital, or Sexual;
• Contraceptive management;
• Cosmetic and reconstructive surgery (except as required by the Women’s Health and Cancer Rights Act);
• Custodial convalescent care;
• Dental services, except those required as the result of an accident and rendered within six months of the accident; o Furnished in any setting other than a dentist’s office for the prevention or correction of teeth irregularities and malocclusion of jaws by wire appliances, braces, or other mechanical aids, or any other care, repair, removal, replacement, or treatment of the teeth, or surrounding tissues, except, (1) When necessitated by damage to sound natural teeth or surrounding issues as a result of a covered injury, or (2) For the excision of impacted unerupted teeth or of a tumor or cyst, or incision and drainage of an abscess or cyst, or (3) For any other surgical procedure not involving any tooth structure, alveolar process, or gingival tissues;
• Domestic violence;
• Donor expenses;
• Drug testing;
• Education diagnosis (including but not limited to: development testing; ADHD, etc.);
• Endoscopic plantar fasiatom (heel spur);
• Experimental or obsolete procedures. The Fund will not pay for any procedure if it is not generally regarded as effective or if it is experimental in the sense that its effectiveness is not generally recognized;
• Genetic testing or counseling, chromosome testing and counseling, unless required with amniocentesis;
• Hair loss including but not limited to any and all medications. Wigs will be covered only according to the Woman’s Health and Cancer Rights Act;
• Hazardous activity, (i.e. jet skiing, motorcycling, ATV’s, snowmobiling, sky diving and bungee jumping);
• Holistic medical services;
• Confinement in a hospital-owned and operated by the United States Government or any agency thereof; or for the service, treatment or supplies, furnished by or at the direction of the United States Government or any agency thereof;
• Confinement in a hospital-owned or operated by a state, province or political subdivision, unless there is an unconditional requirement on the part of the covered person to pay such expenses without regard to any liability against others, contractual or otherwise;
• Hyperbaric oxygen treatment;
• Hypnosis;
• Immunizations, except as allowed in the Prescription Plan and administered in a participating pharmacy;
• Impotence;
• Treatment of infertility including but not limited to artificial insemination, in-vitro fertilization or reversal of elective sterilization;
• Infrared coagulation of hemorrhoids;
• An injury or an illness that is employment-related or that is eligible under the Worker's Compensation Law, Occupational Disease Law or similar laws. This exclusion does not apply to the Accidental Death and Dismemberment Benefit. If you fail to file for workmen’s compensation when injured on the job, the Fund will not be responsible for and charges in connection with that illness or injury;
• An injury for which the Participant is entitled to recover from another person or organization;
• For membership in, or fees, dues or charges incurred with regard to recreational facilities or fitness centers, even though prescribed by a physician;
• Medical eye exam, when not performed by an ophthalmologist. (this does not include your vision exam through the Optical Benefits Plan;
• Any treatment or stay in a Nursing Home;
• Radial Keratotomy;
• Services or supplies, which are furnished for personal conveniences such as air conditioners, humidifiers, physical fitness equipment, TENS units, muscle/bone stimulators or other such devices;
• Services rendered by a non-network or non-participating provider;
• Private duty nursing;
• Treatment of Temporomandibular Joint Syndrome (TMJ), Temporomandibular Joint Dysfunction or other condition of the joint linking the jaw bone (Mandible) and skull and the complex of muscles, nerves and other tissue related to the joint;
• Transsexual changes and/or surgeries and the treatment thereof;
• Varicose veins services and/or treatments (endovenous leg ablation procedures) if for cosmetic purposes;
• Services, supplies or treatment which are not prescribed as medically necessary by a physician or cost containment group. This exclusion also applies to any hospital confinement (or any part of a confinement) that is not recommended or approved by a physician;
• Obesity, weight control programs or any other type of service for weight control, whether it relates to illness or not;
• Any injury incurred during any organized sports or recreation program conducted by a school, college or other social organization and/or any injury coverable by coverage of said school, college, university or other social organization;
• Emergency Room Services to treat routine ailments, because you have no regular physician, or because it is late at night (and the need for treatment is not sudden or serious);
• Expenses incurred as a result of participation in activities which would constitute a felony, riot, insurrection, or domestic violence and/or injury due to the use of guns, firearms, etc.;
• Any services rendered by the claimant's immediate family;
• Any charges which you or your dependents are not required to pay;
• Bariatric Weight Reduction Surgery;
• Transplants;
• Pain management;
• Podiatry services for funguses, toenails, weak, strained, flat feet, bunions, imbalances, corns, or calluses (except if the patient is diabetic);
• Treatment of corns, calluses or toenails, except removing nail roots and care prescribed by an M.D. or D.O. treating metabolic or peripheral vascular disease;
• Any treatment not deemed medically necessary;
• Unnecessary services or supplies;
• Services provided for vocational and/or educational training purposes; • Coverage for medical services provided outside the United States;
• Ultrasound and/or sonogram will be limited to 2 for each pregnancy; non-stress tests limited to 2 per pregnancy;
• Expenses incurred as a result of war or an act of war, declared or undeclared;
• Any service not listed as a covered benefit is excluded.
