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2012 Benefit Plan Comparison
BlueOptions
BlueChoice
Benefits
Coverage represents BluePreferred and BlueChoice Network Levels Only. Coverage represents In-network coverage only. Out-of-network is subject to the deductible and then Out- of-network is subject to deductible then Premiums
Benefit Period
Calendar Year – January 1 through December 31 Office Visit Copay
Calendar Year
Deductible
*$250 deductible credit applies if HRA taken after 1/1/2012. Must be credited prior to claims payment, no retro claims adjustments will be allowed. Inpatient
After calendar year deductible: BluePreferred Network – 80% After calendar year deductible: BlueChoice Network – 80% Hospitalization
Per Occurrence
Deductible
$250 per occurrence for Out-of-network Inpatient hospitalization Per Occurrence Deductible is in addition to the Calendar Year Coinsurance
After Deductible
Out Of Pocket
Lifetime Maximum
BlueOptions
BlueChoice
Benefits
Coverage represents In-network coverage only. Out-of-network is BlueChoice Network Levels Only. Out- of-network is subject to deductible subject to the deductible and then covered at 50% of allowable charge. Preventative Services listed below are Covered at 100% of allowed charge in and out of network Preventative Care
In the event that a follow up exam or test is required due to a medical condition the services would then apply to regular medical benefits. Additional Preventive Care Services not listed may be covered at 100% of the allowable charge. For further information, please contact Immunizations
Routine Office Visit Exam Guidelines
Routine for women and men ages 19 and older, one exam every calendar year Bone Density Testing
Bone density testing when ordered or performed by a Physician or other Provider, limited to one screening per calendar year Gynecological Exam
One Routine Gynecological Exam every calendar year Colorectal Exam
Colorectal cancer examinations and laboratory tests for cancer for any non-symptomatic Subscriber, in accordance with standard, accepted published medical practice guidelines for colorectal cancer screening Mammograms
One baseline screening between ages 35-39. One annual screening age 40 and over PSA (Prostate Specific Antigen) Test
Age 40 and older one exam every calendar year Top 75 Generics - See Page 5 on this Document for List.
Prescription
Selected Generics: $4.00/34 days supply; $10.00/90 day. Tier 1 - Other Generics
Tier 2 -Preferred Drugs: $50.00
Tier 3 - Non-Preferred Drugs: $100.00
Specialty Drugs
If cost of the prescription is less than the maximum copayment, then the copayment will be the cost of the prescription.
Based on a 34 day supply or 200 dose units, whichever is less
*Reduced co-pays on the BlueOptions plan only may be available for members actively engaged and participating in a Diabetes or Coronary Artery Disease Management
program with BCBS. For more information please contact Customer Service at 1-877-258-6781.
BlueOptions
BlueChoice
Benefits
Coverage represents BluePreferred and BlueChoice Network Levels Coverage represents In-network coverage only. Out-of-network is subject to the Only. Out- of-network is subject to deductible then covered at 50% of deductible and then covered at 50% of allowable charge. After calendar year deductible: BlueChoice Network – 80% Treatment &
BluePreferred Network – 80% BlueChoice Network – 70% Diagnosis includes autism, childhood disintegrative disorders, Asperger’s Rhett’s syndrome (See benefits book for additional benefits and limitations) Subject to Deductible and Coinsurance Chiropractic
deductible: BluePreferred Network – 80% BlueChoice After calendar year deductible: BlueChoice Network – 80% Manipulative
of allowed charges Limited to 25 visits including physical therapy and Limited to 25 visits including physical therapy and occupational therapy visits Contraceptive
deductible: BluePreferred Network – 80% BlueChoice After calendar year deductible: BlueChoice Network – 80% Services
100% of allowed charges in conjunction with an office visit Diagnostic Lab
Cat Scans, MRIs, etc are subject to calendar year deductible
Durable Medical
deductible: BluePreferred Network – 80% BlueChoice After calendar year deductible: BlueChoice Network – 80% Equipment (DME)
of allowed charges Precertification required for items over $4,000 of allowed charges Precertification required for items Not a covered benefit except for children Hearing Aids
children up to age 18; Audiological services/hearing aids are covered as up to age 18; Audiological services/hearing aids are covered as durable medical equipment After calendar year deductible: BlueChoice Network – 80% BluePreferred Network – 80% BlueChoice Network – 70% After calendar year deductible: BlueChoice Network – 80% BluePreferred Network – 80% BlueChoice Network – 70% Benefits
BlueOptions Coverage represents BluePreferred and BlueChoice
BlueChoice
Network Levels Only. Out- of-network is subject to deductible then Coverage represents In-network coverage only. Out-of-network is subject to the deductible and then covered at 50% of allowable charge. Infertility
deductible: BluePreferred Network – 80% BlueChoice Services
Benefits are available for diagnosis and injections only Benefits are available for diagnosis and injections only Maternity
office visit copay. Remaining office visits,delivery charges, hospitalization, Remaining office visits,delivery charges, and anesthesia are covered after calendar year deductible: BluePreferred Network – 80% BlueChoice Network – 70% *A $250 deductible credit is available for Blue Options members actively
engaged and participating in the
Special Beginnings program with
BCBS. For more information please contact Customer Service at 1-877-
258-6781.
100% of allowed charges Medically necessary ground, air, or 100% of allowed charges Medically necessary ground, air, or non- emergency transport Transportation
*Out of Network providers can balance bill for any amounts billed over the allowed amount. *Out of Network providers can balance bill for any amounts billed over the Mental Health
deductible: BluePreferred Network – 80% BlueChoice Inpatient
Mental Health
deductible: BluePreferred Network – 80% BlueChoice Outpatient
Physical and
deductible: BluePreferred Network – 80% BlueChoice Occupational
of allowed charges Limited to 25 visits including chiropractic Limited to 25 visits including chiropractic visits After calendar year deductible: BlueChoice Network – 80% Skilled Nursing
BluePreferred Network – 80% BlueChoice Network – 70% Facility
Precertification required Limited to 100 inpatient days per year BlueChoice
Benefits
BlueOptions
Coverage represents BluePreferred and BlueChoice Network Levels Coverage represents In-network coverage only. Out-of-network is subject to the Only. Out- of-network is subject to deductible then covered at 50% of deductible and then covered at 50% of allowable charge. Temporomandibular
Joint Disfunction
Transplants
ALPRAZOLAM TAB 0.5MG MELOXICAM TAB 15MG AMLODIPINE TAB 10MG METFORMIN TAB 1000MG AMOX/K CLAV TAB 875MG METFORMIN TAB 500MG ER AMOXICILLIN CAP 500MG METHYLPRED PAK 4MG AMOXICILLIN SUS 400/5ML METOPROLOL TAB 100MG ER APAP/CODEINE TAB 300-30MG METOPROLOL TAB 25MG ER Prescription
AZITHROMYCIN TAB 250MG METOPROLOL TAB 50MG ER Generics
*This listing has
CEPHALEXIN CAP 500MG NITROFURANTN CAP 100MG changed from the 2011 CHERATUSSIN SYP AC OMEPRAZOLE CAP 20MG
benefits. This listing is
a representation of the CIPROFLOXACN TAB 500MG OXYCOD/APAP TAB 5-325MG
top 75 utilized
CYCLOBENZAPR TAB 10MG PANTOPRAZOLE TAB 40MG generics from the 2011 DOXYCYCL HYC CAP 100MG PAROXETINE TAB 20MG
plan year. Please
FLUCONAZOLE TAB 150MG POT CHLORIDE CAP 10MEQ ER check your
prescriptions carefully FLUTICASONE SPR 50MCG PRAVASTATIN TAB 40MG
to see if they fall within FOLIC ACID TAB 1MG PREDNISONE TAB 10MG
this new
FUROSEMIDE TAB 20MG PREDNISONE TAB 20MG listing
FUROSEMIDE TAB 40MG PROMETH/COD SYP 6.25-10 GABAPENTIN CAP 300MG PROMETHAZINE TAB 25MG GIANVI TAB 3-0.02MG SERTRALINE TAB 100MG HYD POLST-CH LIQ LOR POLS SERTRALINE TAB 50MG HYDROCHLOROT TAB 25MG SIMVASTATIN TAB 20MG HYDROCO/APAP TAB 10-325MG SIMVASTATIN TAB 40MG HYDROCO/APAP TAB 10-500MG SMZ/TMP DS TAB 800-160 HYDROCO/APAP TAB 5-500MG SPRINTEC 28 TAB 28 DAY HYDROCO/APAP TAB 7.5-325 TAMSULOSIN CAP 0.4MG HYDROCO/APAP TAB 7.5-500 TIZANIDINE TAB 4MG IBUPROFEN TAB 800MG TRAMADOL HCL TAB 50MG LEVOTHYROXIN TAB 100MCG TRINESSA TAB LEVOTHYROXIN TAB 50MCG TRI-SPRINTEC TAB LEVOTHYROXIN TAB 75MCG VALACYCLOVIR TAB 1GM LISINOP/HCTZ TAB 20-12.5 VALACYCLOVIR TAB 500MG LISINOP/HCTZ TAB 20-25MG VENLAFAXINE CAP 150MGER LISINOPRIL TAB 10MG VENLAFAXINE CAP 75MG ER LISINOPRIL TAB 20MG VITAMIN D CAP 50000UNT LISINOPRIL TAB 40MG ZOLPIDEM TAB 10MG

Source: http://www.langston.edu/sites/default/files/basic-content-files/2012%20Benefit%20Plan%20Comparison.pdf