Page 13 - NYMets_2018_Benefits_Guide

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at-bat: medical benefits

Highmark bcbs medical plans at-a-glance
preventive care
Premier 80/60 HDHP (with HSA)
in-network out-of-network Routine Preventive Care helps us stay
well or finds problems early, when they
Annual Deductible are easier to treat. Some preventive
Ÿ Individual $1,350
Ÿ Family $2,700 services follow certain guidelines, which
depend on your age, gender, health and
Coinsurance 20% 40%
family history. As a part of your health
Annual Out-of-Pocket plan, you may be eligible to receive
Maximum some of these preventive benefits with
Ÿ Individual $1,500 $3,000 little to no cost sharing when using
Ÿ Family $3,000 $6,000
in-network providers. Some of these
Preventive Care service, screenings and procedures
Ÿ Physical Exams Covered 100% Not covered include:
Ÿ Routine Health Screenings Covered 100% 40% after deductible
Ÿ Routine checkup
Physician Office Visits
Ÿ Primary Care 20% after deductible 40% after deductible Ÿ Pelvic/breast exam
Ÿ Specialist 20% after deductible 40% after deductible
Ÿ Cholesterol, diabetes, Hepatitis B and
Diagnostic Tests 20% after deductible 40% after deductible C screenings
(x-rays, blood work)
Imaging 20% after deductible 40% after deductible Ÿ Colon cancer screening
(CT/PET scans, MRIs) Ÿ Lung cancer screening
Outpatient Surgery 20% after deductible 40% after deductible Ÿ Mammogram
Inpatient Hospital Services 20% after deductible 40% after deductible
Ÿ Pap test
Urgent Care 20% after deductible 40% after deductible
Ÿ Immunizations — flu, chicken pox,
Emergency Room 20% after deductible
measles/mumps/rubella, pneumonia,
Mental Health & shingles, etc.
Substance Abuse
Ÿ Inpatient 20% after deductible 40% after deductible Above is only a partial list. For a full
Ÿ Outpatient 20% after deductible 40% after deductible listing, refer to Highmark’s Preventive
Prescription Drug Coverage Schedule available on ADP.
Retail Pharmacy Subject to medical plan deductible
(up to 31-day supply)
Ÿ Generic 20% after deductible
Ÿ Brand 20% after deductible
Ÿ Brand Non-Formulary 20% after deductible
Mail Order Subject to medical plan deductible
(up to 90-day supply)
Ÿ Generic 20% after deductible
Ÿ Brand 20% after deductible
Ÿ Brand Non-Formulary 20% after deductible

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