BCNEPA - Our Health Plans - Individual Health Plans

Lifetime maximum	$1,000,000 ($25,000 non-renewable lifetime maximum for mental health care)
Annual deductible	$500; $1500 family
Reimbursement	80% of all eligible expenses which exceed the $500 annual deductible (50% in cases of covered medical services for mental health care)
Coinsurance	20% (50% in cases of covered medical services for mental health care)
Hospital Expenses
Semiprivate room	80% after deductible
Nursing services	80% after deductible
Blood and blood plasma	80% after deductible
Dialysis	80% after deductible
Other hospital expenses	80% after deductible
Expenses at Home
Doctor's visits	80% after deductible
Durable medical equipment	80% after deductible
Doctor Expenses
Home and office visit fees	80% after deductible
Physical therapy	80% after deductible (up to 20 visits per calendar year)
Speech and occupational therapy	80% after deductible (up to 12 visits per calendar year)
Medicines and Aids
Ambulance services	80% after deductible
Durable medical equipment, prosthetics and orthotics	80% after deductible (up to $2500 per calendar year)
Mental Health Care
	50% after deductible
Prescription Drugs
Preferred drug formulary program - 30 days supply	$500 deductible Tier 1 - $10 copayment Tier 2 - $25 copayment Tier 3 - $45 copayment
Mail order program - 90 day	Tier 1 - $20 copayment Tier 2 - $60 copayment Tier 3 - $135 copayment
Prior authorization for certain medications Required after 2 refills at community pharmacy

Note: This summary is an abridged overview of the benefits covered by this plan. It highlights general plan features and is not intended to be a substitute for the terms, provisions, limitations, exclusions and conditions imposed by the controlling Blue Cross of Northeastern Pennsylvania and/or Highmark Blue Shield agreement(s). For information about your specific coverage needs, please contact Customer Service at 1-800-829-8599 or (TTY) 1-866-280-0486.

About Us | Careers | News Center | Notice of Privacy Practice | Privacy & Security Statement | Terms & Conditions
Serving Bradford, Carbon, Clinton, Lackawanna, Luzerne, Lycoming, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne and Wyoming Counties.
Copyright © 2008, Blue Cross of Northeastern Pennsylvania is an Independent
Licensee of the BlueCross BlueShield Association. All rights reserved.