PPO

Plan Outline

The Empire Blue Cross PPO plan provides in-network benefits, including an extensive network of participating providers covering most medical specialties, as well as out-of-network (non-network) benefits. A network of physicians covering New York City, the New York metropolitan area and nationally, participate in the Empire Blue Cross PPO plan and accept as payment a fee schedule arranged with Empire Blue Cross. When treatment is rendered by an in-network provider, the only charge to the participant is a small co-payment, mostly $20 (for a few specific services co-payments vary between $15 and $50). On the other hand, the participant may also be treated by a physician who is not a participating practitioner in the plan. Medical services rendered by non-participating (out-of-network) providers, when covered, will be reimbursed at 80 per cent, subject to the deductible and 20 per cent co-insurance and subject to the providers' fees falling within reasonable and customary norms.

If a participating physician refers a patient to another provider who is non-participating, the deductible and 20 per cent co-insurance will apply to reimbursement of the cost of the services rendered by the non-participating provider.

A number of diagnostic laboratories are participating providers under the Empire Blue Cross PPO plan. When laboratory tests are required, it is important that the physician be advised to send the tests to a participating laboratory, if possible. If this is done, the cost of the test will be paid in full and will not be subject to the normal deductible and co-insurance.

Empire Blue Cross health insurance plans have a network of hospitals worldwide which bills Empire directly for any medical services rendered. For all outpatient and professional medical care you pay the provider and submit a claim, using the International Claim form.

Premiums

The new 2012 premium rates and related percentages of salary contribution are shown on the premium schedule.