Page 12 - NYMets_2018_Benefits_Guide

at-bat: medical benefits

Highmark bcbs medical plans at-a-glance
Choice Plus 100/80 PPO Choice 90/70 PPO
in-network out-of-network in-network out-of-network
Annual Deductible
Ÿ Individual None $500 $250 $500
Ÿ Family None $1,000 $500 $1,000
Coinsurance 0% 20% 10% 30%
Annual Out-of-Pocket
Maximum
Ÿ Individual None $1,000 $2,500 $3,000
Ÿ Family None $2,000 $5,000 $6,000
Preventive Care
Ÿ Physical Exams Covered 100% Not covered Covered 100% Not covered
Ÿ Routine Health Screenings Covered 100% 20% after deductible Covered 100% 30% after deductible
Physician Office Visits
Ÿ Primary Care $15 copay 20% after deductible $15 copay 30% after deductible
Ÿ Specialist $15 copay 20% after deductible $15 copay 30% after deductible
Basic Diagnostic Tests Covered 100% 20% after deductible 10% after deductible 30% after deductible
(x-rays, blood work)
Advanced Imaging Covered 100% 20% after deductible 10% after deductible 30% after deductible
(CT/PET scans, MRIs)
Outpatient Surgery Covered 100% 20% after deductible 10% after deductible 30% after deductible
Inpatient Hospital Services Covered 100% 20% after deductible 10% after deductible 30% after deductible
Urgent Care $15 copay 20% after deductible $15 copay 30% after deductible
Emergency Room $100 copay $100 copay $100 copay $100 copay
Mental Health &
Substance Abuse
Ÿ Inpatient Covered 100% 20% after deductible 10% after deductible 30% after deductible
Ÿ Outpatient $15 copay 20% after deductible $15 copay 30% after deductible
Prescription Drug Coverage
Retail Pharmacy
(up to 31-day supply) Mandatory generic program Mandatory generic program
Ÿ Generic $10 $10
Ÿ Brand $20 $20
Ÿ Brand Non-Formulary $35 $35
Mail Order
(up to 90-day supply) Mandatory generic program Mandatory generic program
Ÿ Generic $20 $20
Ÿ Brand $40 $40
Ÿ Brand Non-Formulary $70 $70

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