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		80% coverage Subject to deductible			100% coverage		80% coverage Subject to deductible
Emergency Medical/ Accident		Balance after Medicare Emergency room charges 100% coverage when rendered within 72 hours		Emergency room charges 100% coverage when rendered within 72 hours		100% coverage $35 copay-waived if admitted Not subject to deductible					100% coverage $35 copay - waived if admitted Not subject to deductible
Ambulance Emergency		80%; (Major Medical		80%; (Major Medical		80%		80%			100% coverage		80% coverage
Ambulance non-emergency		80%; subject to deductible (Major Medical)		80%; subject to deductible (Major Medical)		80%		80% coverage Subject to deductible			100% coverage		80% coverage
Dialysis, Chemotherapy, Radiation Therapy		Balance after Medicare 100% coverage		100% coverage		100% coverage		80% coverage Subject to deductible			100% coverage		80% coverage Subject to deductible
Dialysis, Chemotherapy, Radiation Therapy		Balance after Medicare 100% coverage		100% coverage		100% coverage		80% coverage Subject to deductible			Precertification required
Cardiac Rehabilitation		80%; subject to deductible (Major Medical)		80%; subject to deductible (Major Medical)		100% coverage 3 times / week for 12 weeks / calendar year		80% coverage 3 times / week for 12 weeks / calendar year Subject to deductible			100% coverage		80% coverage Subject to deductible
Cardiac Rehabilitation		80%; subject to deductible (Major Medical)		80%; subject to deductible (Major Medical)		100% coverage 3 times / week for 12 weeks / calendar year					Subject to deductible
Occupational Therapy		Balance after Medicare Subject to deductible and 20% coinsurance (when billed by a hospital)		Subject to deductible and 20% coinsurance (when billed by a hospital)		100% coverage 36 visit max/calendar year combined for physical therapy, occupational therapy & speech therapy		80% coverage 36 visit max/calendar year combined for physical therapy, occupational therapy & speech therapy Subject to deductible			100% coverage		80% coverage Subject to deductible
Occupational Therapy											45 visits per calendar year combined with PCP and self-referred services Precertification required
Physical Therapy		Balance after Medicare Inpatient: 100% coverage Outpatient: 100% coverage for 90 days following hospital admissions: other outpatient charges Subject to Major Medical deductible and 20% coinsurance		Inpatient: 100% coverage Outpatient: 100% coverage for 90 days following hospital admissions: other outpatient charges Subject to deductible and 20% coinsurance		100% coverage 36 visit max/calendar year combined for physical therapy, occupational therapy & speech therapy		80% coverage 36 visit max/calendar year combined for physical therapy, occupational therapy & speech therapy Subject to deductible			100% coverage		80% coverage Subject to deductible
Physical Therapy											45 visits per calendar year combined with PCP and self-referred services Precertification required
Respiratory Therapy		Balance after Medicare Inpatient: 100% coverage Outpatient: 100% coverage for 90 days following hospital admission: other outpatient charges Subject to Major Medical deductible and 20% coinsurance		Inpatient: 100% coverage Outpatient: 100% coverage for 90 days following hospital admission: other outpatient charges Subject to deductible and 20% coinsurance		100% coverage		80% coverage Subject to deductible			100% coverage		80% coverage Subject to deductible
Speech Therapy		Subject to deductible and 20% coinsurance (when billed by a hospital)		Subject to deductible and 20% coinsurance (when billed by a hospital)		100% coverage		80% coverage			100% coverage		80% coverage Subject to deductible
Speech Therapy						36 visit max/calendar year combined for physical therapy, occupational therapy & speech therapy					45 visits per calendar year combined with PCP and self-referred services Precertification required
Durable Medical Equipment Orthotics & Prosthetics		Subject to deductible and 20% coinsurance		Subject to deductible and 20% coinsurance		100% coverage		80% coverage			100% coverage		80% coverage Subject to deductible
Durable Medical Equipment Orthotics & Prosthetics		Subject to deductible and 20% coinsurance		Subject to deductible and 20% coinsurance		$5,000 maximum per calendar year Subject to deductible					$2,500 annual maximum Precertification required
Home Health Care		Balance after Medicare 100% coverage 100 visits per benefit period following hospital discharge. Precertification required		100% coverage 100 visits per benefit period following hospital discharge. Precertification required		100% coverage Unlimited visits		80% coverage $500 penalty if late Precertification Unlimited visits Subject to deductible			100% coverage		80% coverage Subject to deductible
Home Health Care						100% coverage Unlimited visits					Precertification required
Hospice		Balance after Medicare 100% coverage Covered with $8,000 maximum (Blue Cross) Precertification Required		100% coverage Covered with $8,000 maximum (Blue Cross) Precertification Required		100% coverage 180 days maximum coverage (lifetime) Respite care: max of 5 days every three months Precertification Required		80% coverage 180 days maximum coverage (lifetime) Respite care: max of 5 days every three months Precertification Required Subject to deductible			100% coverage		80% coverage Subject to deductible
Hospice											180 day lifetime maximum for self-referred services only Precertification required
Bony Impacted Teeth		Not Covered		Not Covered		Not Covered		Not Covered			Not covered			Not covered
Oral Surgery		100% coverage		100% coverage		100% coverage		80% coverage			100% coverage		80% coverage Subject to deductible
Prescription Drugs with mail order		Tier 1 - $10 Tier 2 - $20 Tier 3 - $35 Mail order – Tier 1 - $10 Tier 2 - $40 Tier 3 - $70 Oral contraceptives covered 30 day supply in retail pharmacy; 90 day supply through mail order No mandatory generic provision		Tier 1 - $10 Tier 2 - $20 Tier 3 - $35 Mail order – Tier 1 - $10 Tier 2 - $40 Tier 3 - $70 Oral contraceptives covered 30 day supply in retail pharmacy; 90 day supply through mail order No mandatory generic provision		Tier 1 - $10 Tier 2 - $20 Tier 3 - $35 Mail order – Tier 1 - $10 Tier 2 - $40 Tier 3 - $70 Oral contraceptives covered 30 day supply in retail pharmacy; 90 day supply through mail order No mandatory generic provision		Non network pharmacies not covered			Tier 1 - $10 Tier 2 - $20 Tier 3 - $35 Mail order – Tier 1 - $10 Tier 2 - $40 Tier 3 - $70 Oral contraceptives covered 30 day supply in retail pharmacy; 90 day supply through mail order No mandatory generic provision		Non network pharmacies not covered
Inpatient Mental Health		Balance after Medicare 100% coverage (Blue Cross) 30 days per calendar year Precertification required		100% coverage (Blue Cross) 30 days per calendar year Precertification required		100% coverage		80% coverage $500 penalty if late Precertification			100% coverage		80% coverage Subject to deductible
Inpatient Mental Health						30 days / calendar year					30 days/calendar year Precertification required
Outpatient Mental Health		Balance after Medicare (50%) 20% (Blue Shield)		50% (Major Medical)		50%		50%			100% coverage $10 copay		80% coverage Subject to deductible
Outpatient Mental Health		Balance after Medicare (50%) 20% (Blue Shield)		50% (Major Medical)		60 days / calendar year					60 visits/calendar year Precertification required
Inpatient Substance Abuse		Balance after Medicare 100% coverage 30 days per 12 month period 90 day lifetime maximum Precertification required		100% coverage 30 days per 12 month period 30 days/calendar year 90 day lifetime maximum Precertification required		100% coverage 80% coverage				$500 penalty if late Precertification	1^st course 100% coverage 2^nd course -50% 1^st course 80% coverage 2^nd course -50%			Subject to deductible
Inpatient Substance Abuse						30 days/calendar year 90 day lifetime maximum Precertification required					30 days/calendar year 90 day lifetime maximum Precertification required
Outpatient Substance Abuse		Balance after Medicare 100% coverage 30 visits/calendar year Additional 30 visits or equivalent partial visits may be exchanged on a 2:1 basis for up to 15 additional inpatient rehabilitation days		100% coverage 30 visits/calendar year Additional 30 visits or equivalent partial visits may be exchanged on a 2:1 basis for up to 15 additional inpatient rehabilitation days		100% coverage 30 visits/calendar year Additional 30 visits or equivalent partial visits may be exchanged on a 2:1 basis for up to 15 additional inpatient rehabilitation days		80% coverage 30 visits/calendar year Additional 30 visits or equivalent partial visits may be exchanged on a 2:1 basis for up to 15 additional inpatient rehabilitation days Subject to deductible			100% coverage		80% coverage Subject to deductible
Outpatient Substance Abuse											30 visits maximum/year Lifetime maximum 120 visits - may exchange 30 outpatient days on a 2:1 basis for 15 additional inpatient rehabilitation days Precertification required
	Detoxification		Balance after Medicare 100% coverage 7 days per admission 4 admissions per lifetime Precertification required		100% coverage 7 days per admission 4 admissions per lifetime Precertification required		100% coverage 7days/admission 4 admissions per lifetime		80% coverage $500 penalty for late Precertification 7 days/admission 4 admissions per lifetime Subject to deductible			100% coverage			80% coverage Subject to deductible
	Detoxification						100% coverage 7days/admission 4 admissions per lifetime					7 days/admission 4 admissions per lifetime Subject to deductible


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