BlueCross BlueShield of Western New York

Our health plans

A division of HealthNow New York Inc., an independent licensee of the BlueCross BlueShield Association.

The information in this document is not intended as a contract. Rates vary based on the overall benefit package and are subject to change without notice.

bcbswny.com

WNY_5131_09_12

All of our health plans offer the following benefits:✔ $0 copay on preventive care services

✔ Award-winning health and wellness programs for groups and individuals

✔ Worldwide coverage

✔ Discount programs available

✔ Out-of-network coverage

✔ Health Advocate coaching service

✔ A variety of prescription copay options

classic plans Plans that focus

on wellness and prevention while providing oustanding health care coverage

blended plans Plans that encourage

a healthy lifestyle by involving employees in health care decisions

custom plans Consumer-driven

plans that provide the greatest flexibility in health care coverage

Classic Blended CustomProduct Name HMO 109 Plus HMO 226 Plus Aqua POS 250 Blended Traditional 901 Slate POS 7100 Healthy Balance POS 8100 Healthy Balance PPO 8000 Denim 6150

Option 1 Option 2 Option 1 Option 2 Option 3 Option 1 Option 2 Option 3 Option 4In-Network

Deductible (single/true family) N/A N/A $500/$1,000 $1,000/$2,000 $250/$500 $1,500/$3,000 $1,500/$3,000 $2,000/$4,000 $5,000/$10,000

Coinsurance N/A N/A20% after Aqua allowance

and deductible 20% 80%/20% 0% 20% 20% 0%

Out-of-Pocket Maximum (single/true family) N/A N/A $2,500/$5,000 $5,000/$10,000 $500/$1,000 $5,000/$10,000 $4,000/$8,000 $5,000/$10,000 $5,000/$10,000

Out-of-NetworkDeductible (single/true family) $1,500/$3,000 $1,500/$3,000 $500/$1,000 $2,000/$4,000 N/A $1,500/$3,000 $1,500/$3,000 $2,000/$4,000 $5,000/$10,000

Coinsurance 40% 40% 50% after Aqua allowance and deductible

50% N/A 40% 40% 40% 50%

Out-of-Pocket Maximum (single/true family) $5,000/$10,000 $5,000/$10,000 $10,000/$20,000 $10,000/$20,000 N/A $10,000/$20,000 $10,000/$20,000 $10,000/$20,000 Unlimited

Medical Services

PCP/Specialist Visit $30/$50 $25/$40 20% after first $ coverage and deductible

$25/$40 20% after deductibleand coinsurance

$25/$40after deductible

Deductible/ Coinsurance

Deductible/ Coinsurance

Covered in full after deductible and coinsurance

Well Child Visits and Immunizations Covered in full Covered in full Covered in full after first $ coverage Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Diagnostic X-Rays $50 $40 20% after first $ coverage and deductible

20%subject to deductible Covered in full $40

after deductibleDeductible/ Coinsurance

Deductible/ Coinsurance

Covered in full after deductible and coinsurance

Chiropractic Care $50 $4020% after first $ coverage

and deductible $40 Variable - refer tobenefit summary

$40after deductible

Deductible/ Coinsurance

Deductible/ Coinsurance

Covered in full after deductible and coinsurance

Women’s Services

Maternity CareCovered in full (after copay for

initial visit)

Covered in full (after copay for

initial visit)

20% initial visit after first $ coverage and deductible, inpatient maternity stay - 20% after first $ coverage

$25 applies to initial visit only. Inpatient maternity stay - 20% subject to deductible

Covered in full$25 applies to initial visit only.

Inpatient maternity stay $750 after deductible

Deductible/ Coinsurance

Deductible/ Coinsurance

Covered in full after deductible and coinsurance

Gynecological Office Visits (routine) Covered in full Covered in full Covered in full after first $ coverage Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Mammograms (routine) Covered in full Covered in full Covered in full after first $ coverage Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Hospital Care

Inpatient Hospital $750 $500 20% after first $ coverage20%

subject to deductibleVariable - refer tobenefit summary

$750after deductible

Deductible/ Coinsurance

Deductible/ Coinsurance

Covered in full after deductible and coinsurance

Outpatient Surgery $150 $100 20% after first $ coverage and deductible

20%subject to deductible

Covered in full $150after deductible

Deductible/ Coinsurance

Deductible/ Coinsurance

Covered in full after deductible and coinsurance

ER Visit (copay waived if admitted to hospital) $150 $150 20% after first $ coverage

and deductible20%

subject to deductible Covered in full$150

after deductibleDeductible/ Coinsurance

Deductible/ Coinsurance

Covered in full after deductible and coinsurance

Urgent Care $35 $40 20% after first $ coverage and deductible

20%subject to deductible

Covered in full $50after deductible

Deductible/ Coinsurance

Deductible/ Coinsurance

Covered in full after deductible and coinsurance

Other ServicesWellness Allowance N/A N/A $250 N/A N/A N/A $250 $250 N/A

Durable Medical Equipment 50% 50%20% after first $ coverage

and deductible50%

subject to deductible20% after deductible

and coinsurance50%

after deductibleDeductible/ Coinsurance

Deductible/ Coinsurance

Covered in full after deductible and coinsurance

Home Health Care (40 visits) $30 $25 20% after first $ coverage and deductible $25 Covered in full $40

after deductibleDeductible/ Coinsurance

Deductible/ Coinsurance

Covered in full after deductible and coinsurance

Prosthetic Devices 50% 50% 20% after first $ coverage and deductible

50%subject to deductible

20% after deductibleand coinsurance

50%after deductible

Deductible/ Coinsurance

Deductible/ Coinsurance

Covered in full after deductible and coinsurance

Vision Exam (once every other year) Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Physical, Speech, and Occupational Therapy (30 aggregate visits) $50 $40 20% after first $ coverage

and deductible20%

subject to deductible20% after deductible

and coinsurance$40

after deductibleDeductible/ Coinsurance

Deductible/ Coinsurance

Covered in full after deductible and coinsurance

Prescription DrugsGeneric/Formulary/Non-Formulary Variety of options available Variety of options available Variety of options available Variety of options available Variety of options available Variety of options available Variety of options available Variety of options available Variety of options available

Mail Order Drugs 2.5 times copay for 90-day supply

2.5 times copay for 90-day supply

2.5 times copay for 90-day supply

2.5 times copay for 90-day supply Available, but not mandatory 2.5 times copay

for 90-day supply2.5 times copay

for 90-day supply2.5 times copay

for 90-day supply2.5 times copay

for 90-day supply

Dependent CoverageDependent/Student (until age) 26/26 26/26 26/26 26/26 26/26 26/26 26/26 26/26 26/26

Network HMO 100 HMO 200 POS 100 POS 200 POS 100 POS 100 PPO POS 100