Mexico Central School District
$50 Deductible with Integrated Rx
A nonprofit independent licensee of the BlueCross BlueShield Association
With Excellus BlueCross BlueShield, you get what you expect from
Blue plus a whole lot more such as:
• More doctors, specialists, and hospitals to choose from
• Exclusive discounts on health-related products and services
• Free fitness and nutrition program with StepUp
• Answers to your health questions online
• Local customer service
In this booklet you will find:
• An easy-to-understand chart that summarizes this plan’s
unique benefits and coverage*
• A glossary of terms to help you understand your coverage
Visit us at myexcellusplan.com/cnycoop
*This benefit summary is not a contract or binding agreement; it is a summary of benefits and services.
For complete details, please refer to your Member Certificate.
Our policies and practices regarding the collection, use, and disclosure of personal health information
are available at excellusbcbs.com and Member Services.
Health plan terms
To help you better understand our plans and your coverage, here
are a few definitions* for frequently used health care terms.
Primary Care Physician (PCP)—A doctor who serves as your health care manager and
coordinates virtually all of the health care services you routinely receive.
Participating Provider Benefits—The coverage available when you receive services from
a provider who participates in your health plan.
Non-Participating Provider Benefits—The coverage available when you receive services
from a provider who does not participate in your health plan. Some plans may not include
Allowed Amount—The maximum amount your health plan will pay for a specific
service. Participating providers agree to accept the allowed amount as payment in full.
Coinsurance—A cost-sharing method that requires you pay a portion of the allowed
amount for certain medical services.
Deductible—A set dollar amount you pay for covered services you receive before your
insurer will make a payment.
Out-of-pocket maximum—The maximum amount of deductible and coinsurance
payments that you will pay for health services each calendar year.
*Some definitions may vary slightly by plan. In case of a conflict between your legal plan documents and this information, the plan
documents will govern.
Summary of Benefits
Hospitalization – Paid in Full • Cervical Cancer Screening – Once Per Calendar Year
Inpatient Services • Radiation Therapy
• Inpatient Hospitalization – Unlimited • Chemotherapy
• Skilled Nursing Facility – 100 Days Per Calendar Year • Kidney Dialysis
• Inpatient Physical Rehabilitation – 30 Days Per Calendar Year • Provider Services Rendered for Emergency Condition
• Inpatient Chemical Dependence and Abuse Rehabilitation
• Elective Sterilization
and Detoxification – Unlimited
• Outpatient Mental Health Care – Unlimited
• Inpatient Mental Health Care – Unlimited
Enhanced Medical Benefits
• Calendar Year Deductible
• Home Health Care – 60 Visits Per Calendar Year Deductible: $50 Individual / $150 Family
• Hospice Care – Unlimited • 20% Coinsurance Applies Until the $1,000 Individual /
• Ambulance Services $3,000 Family Out-of-Pocket Maximum is
Satisfied. Excluded Deductible
• $5,000,000 Lifetime Maximum
• Pre-surgical Testing • Office Visits
• Laboratory, Pathology and Diagnostic Imaging Services • Chiropractic Care
• Durable Medical Equipment, Prosthetic Devices and
• Kidney Dialysis
• Radiation Therapy
• Additional Skilled Nursing and Inpatient Physical
• Chemotherapy Rehabilitation – No Deductible or Coinsurance
• Emergency Room Care for Emergency Conditions • Physical Therapy, Occupational Therapy, Speech Therapy –
• Chemical Dependency Visits – Unlimited 100 Visits Per Calendar Year
Medical/Surgical Benefits – Participating Physicians • Additional Home Health Care – 325 Visits Per Calendar Year
Paid in Full
• Treatment of Diabetes – No Deductible or Coinsurance
• Surgery • Reproductive Procedures Including In-Vitro Fertilization
• Anesthesia and Assisted Reproductive Technology
• Additional Surgical Opinions and Second Medical Opinions
Integrated with medical including coinsurance, deductibles, Out-
• Inpatient Medical Care Visits Of-Pocket Maximums and Lifetime Maximums.
• Laboratory Pathology and Diagnostic Imaging Services •
Eligibility (Family Coverage):
• Maternity Care
• Dependent to Age 19
• Adult Routine Physical Exams – Once Per Calendar Year
• Full-time College Student to Age 25
• Adult Routine Immunization
• Age Appropriate Well Child Visits and Immunizations to Age 19
Please Note: This is an outline of benefits only. Official benefits and conditions of coverage are outlined in your member certificate.
Professional Non-participating Provider In-area covered at 100% of current Medicare National rates; Out-of-area covered at 150% of
current Medicare National rates. The following services require prior approval: Organ Transplants, Inpatient Chemical Dependence and
Abuse Rehabilitation and Detoxification, Non-Mandated Reproductive Procedures (IVF, GIFT & ZIFT).
Take your first step toward a healthier you.
Excellus BlueCross BlueShield makes finding the information
and support you need easier—resources, savings, and tools
are available online 24/7.
• Find a doctor or specialist online while you’re home
or far away.
• Get instant access to StepUp, our FREE fitness and
• Research over 6,000 health topics.
Mexico CSD Plan 5 Rx INT