Blue Cross Plan “PB”

For Hospital Expenses

 

Benefits available in PARTICIPATING hospitals for services consistent with diagnosis and treatment of conditions for which hospitalization is required:

 

Inpatient Care

 

·         Semi-Private Room & Board (120 days) **

Paid-in-Full

·         Admissions for mental & nervous conditions (45 days)

Paid-in-Full

·         Use of operating, recovery, intensive care, cystoscopic rooms & equipment

Paid-in-Full

·         Use of hospital physiotherapy, oxygen & transfusion equipment

     (not including blood or plasma)

 

Paid-in-Full

·         X-ray, Laboratory, & Pathological Services (including EKG & EEG)

Paid-in-Full

·         All listed drugs, medications, oxygen, visualizing dyes, vaccines, intravenous preparations, sera & biologicals

 

Paid-in-Full

·         Dressings, ordinary splints & plaster casts

Paid-in-Full

 

 

Outpatient Care

 

·         Emergency Accident (visits within 72 hours of occurrence)

Paid-in-Full

·         Minor Surgical Procedures

Paid-in-Full

·         Medical Emergencies (any sudden, unexpected, life-threatening medical condition within 12 hours of the onset of symptoms)

 

Paid-in-Full

·         Pre-Admission Testing (provided reservations have been made for hospital bed & operating room, & surgery takes place within 7 days)

 

Paid-in-Full

·         Diagnostic X-rays & Radiation Therapy (per calendar year)

$250.00

      Laboratory & Pathological Service (per calendar year) including EKG’s - all types

 

·         Annual Cervical Cytological Screening (women age 18 & older)

Paid-in-Full

·         Alcoholism & Substance Abuse (60 visits)

Paid-in-Full *

·         Hospice Care

Paid-in-Full

 

 

Home Care

 

·         Benefits are provided for 40 visits in a calendar year to the extent that required inpatient hospital days are replaced by Home Care through an approved agency

 

Paid-in-Full

 

 

Maternity Benefits (Except Well Baby Nursery Care)

 

·         Normal Delivery

Paid-in-Full

·         Caesarean, Ectopic or Spontaneous Termination

Paid-in-Full

 

*  Subject to contractual limitations for State Mandated Benefits at defined facilities

** An additional 120 days are available provided there is a 90 day separation between

    date of discharge and date of re-admission  

  of Utica-Watertown

 

 

Blue Shield Plan “14X”

for Physician Expenses

 

All payments for the following services are based on a Schedule of Allowances which vary depending upon the actual procedure performed:

 

 

Maximum Allowances

·         Surgical Procedures

                   $2,933.70

·         Assistant Surgeon - when surgical allowance is $100 or more

                        586.74

·         General Anesthesia - based on time schedule

                        967.50

·         Inpatient Hospital Medical Visits                                                (when no surgery or maternity is involved)

 

                     1,674.75

Þ     First day for brief initial examination

                          38.50

Þ     Second through 120th day for brief exam each subsequent day (additional allowance for Intensive & Concurrent Care)

 

                          13.75

·         Mental & Nervous Disorders -

      Inpatient medical care is limited to 45 days per calendar year

 

·         Inpatient Hospital Consultation (per calendar year)

 

Þ     per different disability, limited exam

                          33.00

Þ     per member, limited exam

                          99.00

Þ     per family, limited exam

                        198.00

·         Maternity Benefits -

 

Þ     Normal Obstetrical Delivery (including pre & post natal care)

                        880.00

Þ     Caesarean Section (including pre & post natal care)

                     1,100.00

Þ     Ectopic Pregnancy

                        715.00

Þ     Spontaneous Termination

                        300.30

·         Annual Pelvic Examination & Cervical Cytological Screening (women Age 18 & older)

 

Based on fee schedules *

·         Well Care, Age 0 - 19 with Immunizations

Based on fee schedules *

·         Diagnostic X-rays & Radiation Therapy                                       (per calendar year based on fee schedule)

      Laboratory Services (per calendar year based  on fee schedule)

 

                        250.00

 

                       

·         Special Examinations & Procedures

 

Þ     Cardiac Catheterization (right heart)

                        312.50

·         Second Surgical Opinion - initial consultation, intermediate - All allowance is available in the physician’s office equivalent to a consultation visit in the hospital, providing recommendation for surgery is made by a surgeon & the second opinion is rendered by a board-certified specialist.  This benefit is provided only with respect to a possible inpatient surgical procedure.

                          41.25

 

Dependent Child Coverage to Age 19.

* As defined under State Mandated Benefits