UN Health and Life Insurance Section

Empire Blue Cross PPO

Plan Outline
Pre-certification of Services
Summary of Benefits
Discount Prescription Drug Programme
Participating Pharmacies
Vision Care
Exclusions and Claims
Empire's Internet Site

PPO

Summary of Benefits

BENEFITS	IN-NETWORK	OUT-OF-NETWORK
Annual Deductible	$0	$150 Individual $450 Maximum for a family
Insurance coverage (% at which the plan pays benefits)	100%	80%
Annual Out-of-Pocket Maximum	$0	$1150 Individual $2950 Family in addition to annual deductible
Lifetime Maximum	Unlimited Benefits
Dependent Children	Covered to end of calendar year in which child reaches age 25
Claim Submission	PROVIDER files claims	YOU file claims
HOSPITAL SERVICES AND RELATED CARE COVERAGE
Inpatient^b (except behavioural health) Unlimited days - semiprivate room & board Hospital-provided services Routine nursery care	100%	80% after deductible within the US 100% outside of the US
Outpatient Surgery and ambulatory surgery^b Pre-surgical testing (performed within 7 days of scheduled surgery) Blood- Chemotherapy and radiation therapy Mammography screening and cervical cancer screening	100%	80% after deductible within the US 100% outside of the US
MANDATORY PRE-REGISTRATION^b (1-800-982-8089) Refer to "When to call the Medical Management Program" (Pg. 13)	Pre-registrations are your responsibility	Pre-registrations are your responsibility
*(For emergency admissions, call within 48 hours or next business day if admitted on weekend)*
Emergency Room/Facility^c (initial visit) Accidental injury Sudden and serious medical condition	$35 co-payment (waived if admitted within 24 hours)	$35 co-payment (waived if admitted within 24 hours)
OTHER FACILITY BENEFITS
Home Health Care^b,d Up to 200 visits per calendar year Home Infusion Therapy	100%	1. 80% within US (deductible does not apply) 100% outside of the US 2. Covered in-network only
Outpatient Kidney Dialysis Home, hospital based or free-standing facility treatment	100%	80% after deductible
Skilled Nursing Facility^b Up to 120 days per calendar year	100%	In-network only within the US 80% after deductible outside of the US
Hospice^b Up to 210 days per lifetime	100%	In-network only
Physical Therapy^b Up to 60 inpatient days per calendar year Up to 60 visits combined in home, office or out-patient facility	100% 100% after $15 co-pay	80% after deductible
PREVENTIVE CARE BENEFITS
Annual Physical Exam	$15 co-payment	80% after deductible
Diagnostic Screening Tests	100%	80% after deductible
Prostate Specific Antigen (PSA) Test	100%	80% after deductible
Well Woman Care	$15 co-payment	80% after deductible
Mammography Screning	100%	80% after deductible
Well Child Care(including recommended immunizations)^d Newborn Baby - 1 in-hospital exam at birth Birth to 1 year of age - 7 visits 1 through 2 years of age- 3 visits 3 through 6 years of age - 4 visits 7 up to 19th birthday- annual visits	100%	100%
MEDICAL BENEFITS
Office/Home Visits/Consultations	$15 co-payment	80% after deductible
Surgery	100%	80% after deductible
Surgical Assistant^e	100%	80% after deductible
Anaesthesia^f	100%	80% after deductible
Inpatient Visits/Consultations	100%	80% after deductible
Maternity Care	100%	80% after deductible
Diagnostic X-Rays	100%	80% after deductible
Lab Tests	100%	80% after deductible
Chemotherapy & Radiation Therapy Hospital outpatient or physician's office	100%	80% after deductible
MRIs/MRAs, PET/CAT scans and nuclear cardiology scans^b	100%	80% after deductible
Cardiac Rehabilitation^b	$15 co-payment	80% after deductible
Second Surgical Opiniong	$15 co-payment	80% after deductible
Second Medical Opinion for Cancer Diagnosis	$15 co-payment	80% after deductible
Allergy Testing and Allergy Treatment	$15 co-payment per office visit for testing 100% for testing fees and treatment visits	80% after deductible
Prosthetic, Orthotics and Durable Medical Equipment^j	100%	In-network only
Medical Supplies	100%	100% up to allowed amount
PHYSICAL THERAPY and OTHER SKILLED THERAPIES
Physical Therapy^b 60 inpatient visits, and 60 visits combined in home, office or outpatient facility	100% $15 co-payment	80% after deductible
Occupational, Speech, Vision^b 30 visits combined in home, office or outpatient facility	$15 co-payment	80% after deductible
BEHAVIORAL HEALTH CARE BENEFITS
Mental Health Care^d,j Up to 90 inpatient days per calendar year Up to 60 outpatient visits in office or facility Up to 90 professional visits per calendar year while in an inpatient facility	100% $25 co-payment 100%	80% after deductible
Outpatient Alcohol and Substance Abuse^d,j Up to 60 outpatient visits which include 20 family counselling visits per calendar year	100%	80% after deductible
Inpatient Alcohol and Substance Abuse^d,j Up to 7 days detoxification and 30 days rehabilitation per calendar year	100%	80% after deductible
OTHER BENEFITS
Acupuncture	$15 co-payment	80% after deductible
Chiropractic Care	$15 co-payment $1000 annual limit	80% after deductible $1000 annual limit
Hearing Exam (every 3 yrs) Hearing Appliance	$15 co-payment Not covered	80% after deductible Not covered
Ambulance	100% up to the allowed amount
Prescription Drugs (Card and Mail Order Programme)	- 20% co-payment with a minimum of $5 or cost of Rx and up to a maximum of $20 per prescription - $15 co-payment for mail order for up to 90 days supply from participating mail order vendor	Within US: 60% after deductible Outside US: 80% after deductible(claim form must be filed for reimbursement)
Vision Care Programme (in-network only through a designated group of providers)	- $15 co-payment for 1 exam every 12 months - $10 co-payment for basic frames - $35 co-payment for non-plan eyewear allowance	Out of Network Allowance Exams: $30 Frames: $30 Lenses: single Vision $25 Bifocal $35 Trifocal $45 Contact $75

a In-network services (except Mental Health or Alcohol/Substance Abuse) are those from a provider that participates with Empire or another Blue Cross BlueShield Plan through the BlueCard Program, or a participating provider with another Blue Cross BlueShield Plan that does not have a PPO network and does accept a negotiated rate arrangement as payment-in-full.
b Medical Management Program must pre-approve or benefits will be reduced 50% up to $2,500.
c If admitted, Medical Management must be called within 24 hours or as soon as reasonably possible.
d Combined maximum visits for in-network and out-of-network services.
e If the surgical assistant is an out-of-network provider and is assisting a participating surgeon, payment will be made in full.
f If the anaesthesiologist is an out-of-network provider but is affiliated with a participating hospital, payment will be made in full.
g Charges to member do not apply if the second surgical opinion is arranged through the Medical Management Program.
h If arranged through the Medical Management Program, services provided by an out-of-network specialist will be covered as if the services had been in-network (i.e., subject to the in-network co-payment).
i In-network vendor must call Medical Management to pre-certify.
j Empire Behavioral Health Services must pre-approve or benefits will be reduced 50% up to $2,500. Out-of-network mental health care does not require pre-certification; however, out-patient alcohol and substance abuse visits must be pre-certified. In network mental health services are those from providers that participate with Magellan Behavioral Health.