The University of Scranton - Office of Human Resources

University of Scranton

	BlueCare Senior	BlueCare Traditional	BlueCare PPO		HMO Plus
Benefit	Medicare Supplement		Preferred	Non-Preferred	PCP Referred	Self Referred
Deductible	$100 Maximum 3 per family (Major Medical)	$100 Maximum 3 per family (Major Medical)	None	$200 Maximum 2 per family Does apply toward preferred deductible All services subject to deductible unless otherwise noted	None	$200 Maximum 3 per family All services subject to deductible unless otherwise noted
Annual Coinsurance Maximum Includes coinsurance. Excludes Precertification penalty, co-pays, excess fees, non-covered charges, deductibles, exhausted benefits and riders.	$2,000 (Major Medical)	$2,000 (Major Medical)	Not applicable	$2,000 Maximum 2 per family	None	$1,000 Maximum 3 per family
Lifetime Maximum	$2,000,000 (Major Medical)	$2,000,000 (Major Medical)	Unlimited	$1,000,000	Unlimited	$1,000,000
Precertification Penalty	None	None	None	$500 for late Precertification for facility; 20% for professional	None	$300 for late Precertification for facility
Coinsurance	80% coverage (Major Medical)	80% coverage (Major Medical)	100% coverage	80% coverage	100% coverage	80% coverage
Physician Office Visits	80%; Subject to deductible (Major Medical)	80%; Subject to deductible (Major Medical)	100% coverage $10 copay	80% coverage Subject to deductible	100% coverage $15 copay (PCP) $25 copay (Specialist)	80% coverage Subject to deductible
Physician Office Visits	80%; Subject to deductible (Major Medical)	80%; Subject to deductible (Major Medical)	unlimited visit maximum/calendar year		100% coverage $15 copay (PCP) $25 copay (Specialist)	80% coverage Subject to deductible
Routine GYN Exams/Pap Smear	Balance after Medicare Usual, Customary and Reasonable (UCR) Allowance (Blue Shield)	Usual, Customary and Reasonable (UCR) Allowance (Blue Shield)	100% coverage	80% coverage Not subject to deductible	100% coverage $15 copay (PCP) $25 copay (Specialist)	80% coverage Not subject to deductible
Pediatric Immunizations	Balance after Medicare UCR Allowance (Blue Shield)	UCR Allowance (Blue Shield)	100% coverage	80% coverage Not subject to deductible	100% coverage	80% coverage Not subject to deductible
Adult Immunizations	Balance after Medicare UCR Allowance (Blue Shield)	UCR Allowance (Blue Shield)	100% coverage	80% coverage	100% coverage	80% coverage
Spinal Manipulation	80%; Subject to deductible (Major Medical)	80%; Subject to deductible (Major Medical)	100% coverage	80% coverage	Not covered
Spinal Manipulation	80%; Subject to deductible (Major Medical)	80%; Subject to deductible (Major Medical)	12 visit maximum/calendar year		Not covered
Inpatient Hospital Services	Balance after Medicare 100% coverage (Blue Cross) 365 days Precertification required	100% coverage (Blue Cross) 365 days Precertification required $5 copay per day for first 15 days. $75 max.	100% coverage 365 days	80% coverage 365 days Subject to deductible $500 penalty for late Precertification	100% coverage	80% coverage Subject to deductible
Inpatient Hospital Services			100% coverage 365 days		Precertification required
Outpatient Surgery	Balance after Medicare 100% coverage (Blue Cross) Precertification for selected procedures	100% coverage (Blue Cross) Precertification for selected procedures	100% coverage Precertification for selected procedures	80% coverage Subject to deductible Precertification for selected procedures	100% coverage	80% coverage Subject to deductible
Outpatient Surgery			100% coverage Precertification for selected procedures		Precertification required
Skilled Nursing Facility	Balance after Medicare 100% coverage (Blue Cross) 3 skilled nursing facility days will count as one day in hospital Subject to maximum Blue Cross days available Precertification required	100% coverage (Blue Cross) 3 skilled nursing facility days will count as one day in hospital Subject to maximum Blue Cross days available Precertification required	100% coverage 100 days calendar year	80% coverage $500 penalty if late Precertification 100 days calendar year Subject to deductible	100% coverage	80% coverage Subject to deductible
Skilled Nursing Facility			100% coverage 100 days calendar year		90 days per year when self-referred only Precertification required
Maternity Care	Balance after Medicare UCR Allowance	UCR Allowance	100% coverage	80% coverage	100% coverage	80% coverage Subject to deductible
Maternity Care	Balance after Medicare UCR Allowance	UCR Allowance	Subject to deductible		100% coverage	80% coverage Subject to deductible
Lab Tests/X-rays	Balance after Medicare UCR Allowance	UCR Allowance	100% coverage	80% coverage Subject to deductible	100% coverage	80% coverage Subject to deductible
Mammography 1 per year (age 40+)	Balance after Medicare UCR Allowance	UCR Allowance	100% coverage