Roman Catholic Diocese of Albany
2017 BENEFIT SUMMARY COMPARISON
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| 2017 POINT OF SERVICE In Network |
2017 POINT OF SERVICE Out of Network |
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| Annual Deductible | None | $500 Individual, $1000 Family | ||||||||
| Coinsurance | None | You pay 30% | ||||||||
| Annual Out-of-Pocket Maximum | $6,350 Individual/$12,700 Family | $5,000 Individual/$10,000 Family | ||||||||
| Annual Maximum Benefit | Unlimited | Unlimited | ||||||||
| Lifetime Maximum Benefit | Unlimited | Unlimited | ||||||||
| Dependent Coverage | to Age 26 | to Age 26 | ||||||||
| Inpatient Hospitalization | $500 co-pay | Deductible and Coinsurance | ||||||||
| Outpatient Surgery (Facility Charge) | $75 co-pay | Deductible and Coinsurance | ||||||||
| Well Child Care & PCP visits | Covered In full (up to age 19) | Covered In Network Only | ||||||||
| Annual Gynecological Visit | Covered in full | Covered In Network Only | ||||||||
| Routine Mammograms | Covered In full | Covered In Network Only | ||||||||
| Maternity | $10/ $20/ $25 co-pay (Initial Visit Only), then Covered in full | Deductible and Coinsurance | ||||||||
| Immunizations | Covered in full | Covered In Network Only | ||||||||
| Annual Physical Exam | Covered in full | Covered In Network Only | ||||||||
| Physician Office Visit | $10/ $20/ $25 co-pay | Deductible and Coinsurance | ||||||||
| Specialist Office Visit | $40/ $30/ $25 co-pay | Deductible and Coinsurance | ||||||||
| Diagnostic Radiology | $40/$30/$25 co-pay | Deductible and Coinsurance | ||||||||
| Diagnostic Laboratory Tests** | Covered In full | Deductible and Coinsurance | ||||||||
| Dental | Specialist co-pay $40/$30/$25 | Not covered | ||||||||
| Routine Vision Exam | Covered in full-1 every 2 yrs | Not covered | ||||||||
| Physical, Speach & Occupational Therapy | $40/ $30/ $25 co-pay (30 visits) | Deductible and Coinsurance | ||||||||
| Chiropractic | $40/ $30/ $25 co-pay | Deductible and Coinsurance | ||||||||
| Mental Health Inpatient | $500 co-pay | $500 co-pay, then Deductible | ||||||||
| Mental Health Outpatient | $40/$30/$25 co-pay | Deductible and Coinsurance | ||||||||
| Alcohol/Substance Abuse Inpatient - Detox | $500 co-pay | Deductible and Coinsurance | ||||||||
| Alcohol/Substance Abuse Inpatient - Rehab | $500 co-pay | Deductible and Coinsurance | ||||||||
| Alcohol/Substance Abuse Outpatient | $30/$30/$25 co-pay/visit | Deductible and Coinsurance | ||||||||
| Durable Medical Equipment | 50% co-insurance | Deductible and Coinsurance | ||||||||
| Ambulance | $100 co-pay* | $100 co-pay* | ||||||||
| Emergency Room Care | $100 co-pay* | $100 co-pay* | ||||||||
| Urgent Care | $35/$30/$25 | $35/$30/$25 | ||||||||
| Prescription Drugs (Retail) 30 day supply | $10 Generic/$30 Brand/$50 NF | $10 Generic/$30 Brand/$50 NF | ||||||||
| Prescription Drugs (Mail Order) 90 day supply | $25 Generic/$75 Brand/$125 NF | $25 Generic/$75 Brand/$125 NF | ||||||||
| Inpatient Hospitalization Precertification | Yes | Yes | ||||||||
| Infertility Treatment | Covered-Refer to contract for details | Covered-Refer to contract for details | ||||||||
| Primary Care Physician Required | Yes | No | ||||||||
| Specialty Referral Required | No | No | ||||||||
1. The above comparison is a summary only designed as a quick reference to help you select a plan. More detailed information is in the material distributed by the Plan.
2. Abortions and elective sterilization are excluded from coverage.
3. There are NO Core Benefit Changes for 2017.
4. See other benefit summaries for comparisons of other plans being offered.
5. Visit their website at www.bsneny.com
* Please note: Must be deemed a true life threatening emergency.
** Effective 1/1/16 Lab Corp is no longer participating with Blue Shield.