Health Plan Comparison

BCBS PPO Plan

BU Health Savings Plan

BCBS National PPO Network

Out-of-Network Providers

In-Network

Out-of-Network

BMC Providers

All Other Network Providers

Applied Behavior Analysis

Applied Behavior Analysis
$15 copayment per visit (deductible does not apply) $35 copayment per visit (deductible does not apply) 30% coinsurance after deductible Not Covered Not Covered

Chiropractic Care

Chiropractic Care
$35 copayment per visit (deductible does not apply);
20 visits per calendar year		 $35 copayment per visit (deductible does not apply);
20 visits per calendar year		 30% coinsurance after deductible;
20 visits per calendar year		 12% coinsurance after deductible;
20 visits per calendar year		 30% coinsurance after deductible;
20 visits per calendar year

Drug and Alcohol Treatment

Drug and Alcohol Treatment
Inpatient No charge after deductible Inpatient Low Cost Provider: No Charge after deductible
High Cost Provider: 20% after deductible		 Inpatient 30% coinsurance after deductible Inpatient 12% coinsurance after deductible Inpatient 30% coinsurance after deductible
Outpatient No charge after deductible Outpatient Low Cost Provider: No Charge after deductible
High Cost Provider: 20% after deductible		 Outpatient 30% coinsurance after deductible Outpatient 12% coinsurance after deductible Outpatient 30% coinsurance after deductible
Office Visits $15 copayment per visit (deductible does not apply) Office Visits $35 copayment per visit (deductible does not apply) Office Visits 30% coinsurance after deductible Office Visits 12% coinsurance after deductible Office Visits 30% coinsurance after deductible

Durable Medical Equipment

Durable Medical Equipment
10% coinsurance after deductible 12% coinsurance after deductible 30% coinsurance after deductible 12% coinsurance after deductible 30% coinsurance after deductible

Emergency Room

Emergency Room
$150 copayment per visit(deductible does not apply); copayment waived if held for observation or admitted within 24 hours 12% coinsurance after deductible 12% coinsurance after deductible

Family Planning

Family Planning
$15 copayment per visit (deductible does not apply) $35 copayment per visit (deductible does not apply) 30% coinsurance after deductible 12% coinsurance after deductible 30% coinsurance after deductible

Hospital Benefits

Hospital Benefits
General Hospital No charge after deductible General Hospital Low Cost Provider: 12% after deductible;
High Cost Provider: 20% after deductible		 General Hospital 30% coinsurance after deductible General Hospital 12% coinsurance after deductible General Hospital 30% coinsurance after deductible
Skilled Nursing Facility 10% after deductible;
100-day benefit limit per member per calendar year		 Skilled Nursing Facility 12% after deductible;
100-day benefit limit per member per calendar year		 Skilled Nursing Facility 30% after deductible;
100-day benefit limit per member per calendar year		 Skilled Nursing Facility 12% after deductible;
100-day benefit limit per member per calendar year		 Skilled Nursing Facility 30% after deductible;
100-day benefit limit per member per calendar year

Mental Health Benefits

Mental Health Benefits
Inpatient No Charge after deductible Inpatient Low Cost Provider: No Charge after deductible
High Cost Provider: 20% after deductible		 Inpatient 30% after deductible Inpatient 12% after deductible Inpatient 30% after deductible
Outpatient No Charge after deductible Outpatient Low Cost Provider: No Charge after deductible
High Cost Provider: 20% after deductible		 Outpatient 30% after deductible Outpatient 12% after deductible Outpatient 30% after deductible
Office Visits $15 copayment per visit (deductible does not apply) Office Visits $35 copayment per visit (deductible does not apply) Office Visits 30% coinsurance after deductible Office Visits 12% coinsurance after deductible Office Visits 30% coinsurance after deductible

MRIs, CT scans, Nuclear Cardiac Imaging & Lab Tests

MRIs, CT scans, Nuclear Cardiac Imaging & Lab Tests
No Charge after deductible Low Cost Provider: 12% after deductible;
High Cost Provider: 20% after deductible		 30% coinsurance after deductible 12% coinsurance after deductible 30% coinsurance after deductible

Physical Therapy

Physical Therapy
$15 copayment per visit (deductible does not apply); copayment waived for physical therapy furnished by BU Physical Therapy Center;
up to 60 visits per calendar year		 $35 copayment per visit (deductible does not apply);
copayment waived for physical therapy furnished by BU Physical Therapy Center;
up to 60 visits per calendar year		 30% after deductible;
up to 60 visits per calendar year		 12% after deductible;
up to 60 visits per calendar year		 30% after deductible;
up to 60 visits per calendar year

Physicians’ Services

Physicians’ Services
$15 copayment per visit (deductible does not apply) $35 copayment per visit(deductible does not apply) 30% after deductible 12% after deductible 30% after deductible

Preventive Care

Preventive Care
You pay nothing 30% after deductible You pay nothing 30% after deductible

Preventive Eye Exams

Preventive Eye Exams
You pay nothing 30% after deductible You pay nothing 30% after deductible

Preventive Mental Health Exams

Preventive Mental Health Exams
You pay nothing 30% after deductible You pay nothing 30% after deductible

Deductible Per Calendar Year (single/family)

Deductible Per Calendar Year (single/family)
$500 per member /$1,000 per family $1,000 per member $2,000 per family $2,000 employee only $4,000 per family $4,000 employee only $8,000 per family

Out-of-Pocket Maximum

Out-of-Pocket Maximum
$3,000 per member /$6,000 per family $6,000 per member /$12,000 per family $4,000 employee only $8,000 per family $8,000 employee only $16,000 per family

Lifetime Maximum

Lifetime Maximum
None None

Provider Choice

Provider Choice
You must use a BMC network participating provider. You must use a BCBS National PPO network participating provider. You may use the provider of your choice. You must use a BCBS National PPO network participating provider. You may use the provider of your choice.

Copayment

Copayment
$15 per visit for most covered services $35 per visit for most covered services Depending on the service, generally 30% coinsurance after deductible Depending on the service, generally 12% coinsurance after deductible Depending on the service, generally 30% coinsurance after deductible

Benefit Level

Benefit Level
You pay nothing for inpatient services after deductible is met; $35 copayment per visit for some services You pay 12% for inpatient services at a low cost provider and 20% at a high cost provider after deductible is met; $35 copayment per visit for some services 30% coinsurance for most covered inpatient and outpatient services after deductible is met 12% coinsurance for most covered inpatient and outpatient services after deductible is met 30% coinsurance for most covered inpatient and outpatient services after deductible is met

Claim Forms

Claim Forms
Not Required Required Not Required Required

Prescription Drugs

Prescription Drugs
Out of Pocket Maximum
$2,500 per member / $5,000 per family Retail Pharmacy for up to 30 day supply:
Generic Medications
$10 copaymentPreferred Brand Name
20% coinsurance(minimum cost $45; maximum cost $65/prescription)Non-preferred Brand Name30% coinsurance(minimum cost $65; maximum cost $85/prescription)Home Delivery for up to 90 day supply:30 day supply limit at retail; 90 day supply limit at mail-order or CVS retail Generic Medications
$20 copayment

Preferred Brand Name
20% coinsurance(minimum cost $90; maximum cost $130/prescription)

Non-preferred Brand Name
30% coinsurance(minimum cost $130; maximum cost $170/prescription)

 Not Covered 12% after deductible Not Covered