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1 2008 Health Insurance
Co-payment Comparison Chart (Rochester Area)
E M P I R E P L A N
Blue Cross (Hospital) United HealthCare (Medical) Independent
Blue Choice Community Blue Preferred Care
Health
Network Out of Network Participating Provider Out of Network
HOSPITAL SERVICES
$1,000 of the $1,500 out of
network hospital
Reimbursed 90% up to
Hospital Inpatient Paid in full coinsurance maximum is No cost No cost No cost No cost
$1,500,
reimbursable under Basic
Medical.
$1,000 of the $1,500 out of
network hospital
Greater of 10% or $75
Hospital Outpatient $30, or $35/visit coinsurance maximum is Contact carrier Contact carrier Contact carrier Contact carrier
copay up to $1,500
reimbursable under Basic
Medical.
No copayment if service
Ambulance is provided by admitting $35 $35 $50/trip $50/trip $25/trip $50/trip
hospital.
Basic Medical. Attending
Emergency Room $50 or $60/visit $50 or $60/visit No copayment. physician, radiologist, labs, $50/visit $50/visit $50/visit $50/visit
etc. paid in full.
$10/visit; After
Urgent Care $12, $15 or $18/visit Basic Medical $25/visit $10/visit $25/visit
Hours Care $35/visit
No cost up to 365 No cost up to 120
No cost up to 120 No cost up to 50
Skilled Nursing Facility benefit days. No benefit No cost up to 45 days days/year; max 360
days days
if Medicare primary. days/life
No cost up to 210 No cost up to 210
Hospice No cost; unlimited No cost; unlimited No cost; unlimited
days days
PHYSICIAN SERVICES
$20/visit; $5 for $20/visit; no cost for
$10/visit; no cost for
Office Visit $12, $15 or $18/visit Basic Medical PCP visit for sick $10/visit children to age 4; $10
well child care
children to age 19 children age 5-18
Page 1
2 2008 Health Insurance
Co-payment Comparison Chart (Rochester Area)
E M P I R E P L A N
Blue Cross (Hospital) United HealthCare (Medical) Independent
Blue Choice Community Blue Preferred Care
Health
Network Out of Network Participating Provider Out of Network
Specialty Office Visit $12, $15 or $18/visit Basic Medical $20/visit $10/visit $10/visit $20/visit
Annual Routine Physical $12, $15 or $18/visit Basic Medical $5/visit $10/visit $10/visit $20/visit
$12,$15 or $18/visit. No
Allergy Testing /
cost for allergy Basic Medical Contact carrier Contact carrier Contact carrier Contact carrier
Treatment
desensitization
Chiropractic $12, $15 or $18/visit Contact carrier $20/visit $10/visit $10/visit $20/visit
Family Planning $12, $15 or $18/visit Basic Medical $20/visit $10/visit $10/visit $20/visit
$12, $15 or $18/visit; no
cost at designated Center
Infertility Services Basic Medical. $20/visit $10/visit $10/visit $20/visit
of Excellence; $50,000
lifetime maximum
$12, $15, or $18/visit.
Basic Medical. Also covered
Also covered by Applicable Applicable Applicable
Contraceptive Drugs/ by prescription drug
prescription drug prescription copay prescription copay prescription copay No cost
Devices program subject to
program subject to applies applies applies
copayment.
copayment.
WOMEN'S HEALTH CARE
$30, or $35/outpatient Greater of 10% or $75
Pap Tests $12, $15, or $18/visit Basic Medical $5/visit No cost $10/visit $15/visit
visit copay up to $1,500
$30, or $35/outpatient Greater of 10% or $75
Mammograms $12, $15, or $18/visit Basic Medical $5/visit $10/visit No cost No cost
visit copay up to $1,500
$5 for the first 10 $50 copayment per
Pre/Post Natal No cost Basic Medical No cost No cost
visits pregnancy
$30, or $35/outpatient Greater of 10% or $75
Bone Density Tests $12, $15, or $18/visit Basic Medical $20/visit $10/visit $15/visit $20/visit
visit copay up to $1,500
Page 2
3 2008 Health Insurance
Co-payment Comparison Chart (Rochester Area)
E M P I R E P L A N
Blue Cross (Hospital) United HealthCare (Medical) Independent
Blue Choice Community Blue Preferred Care
Health
Network Out of Network Participating Provider Out of Network
DIAGNOSTIC / THERAPEUTIC SERVICES
$30, or $35/outpatient Greater of 10% or $75
X-Rays $12, $15, or $18/visit Basic Medical $20/visit $10/visit $15/visit $20/visit
visit copay up to $1,500
$30, or $35/outpatient Greater of 10% or $75
Lab Tests $12, $15, or $18/visit Basic Medical No cost No cost No cost $5/day
visit copay up to $1,500
$30, or $35/outpatient Greater of 10% or $75
Pathology $12, $15, or $18/visit Basic Medical No cost No cost No cost $5/day
visit copay up to $1,500
$30, or $35/outpatient Greater of 10% or $75
EKG/EEG $12, $15, or $18/visit Basic Medical $20/visit $10/visit $10/visit $20/visit
visit copay up to $1,500
$15/visit radiation; Radiation no cost;
Radiation / Chemo No cost No cost No cost Basic Medical $20/visit $10/visit
$10/visit chemo Chemotherapy $20/visit
MENTAL HEALTH / SUBSTANCE ABUSE
No cost; unlimited when 90% of billed charges; after No cost; 30 No cost; 30 No cost; 30 No cost; 30 days/year,
Inpatient Mental Health medically necessary $500 coinsurance max, days/year, beyond days/year, beyond 30 days/year, beyond 30 - beyond 30 - contact
(Value Options) covered in full 30 - contact carrier - contact carrier contact carrier carrier
$20/visit; prior $10/visit; prior
$12, $15 or $18/visit; $10/visit; prior $20/visit; prior
authorization authorization
Outpatient Mental Health unlimited when medically Basic Medical Formula authorization required authorization required
required after 20th required after 20th
necessary (Value Options) after 20th visit after 20th visit
visit visit
No cost; 3 stays /
$2,000 annual deductible,
Inpatient Drug / Alcohol lifetime; more may be No cost; max 30 No cost; max 30
50% of network allowance; No cost; max 30 days No cost; max 30 days
Rehab approved case by case days days
1 stay/year, 3 stays/lifetime
(Value Options)
Page 3
4 2008 Health Insurance
Co-payment Comparison Chart (Rochester Area)
E M P I R E P L A N
Blue Cross (Hospital) United HealthCare (Medical) Independent
Blue Choice Community Blue Preferred Care
Health
Network Out of Network Participating Provider Out of Network
$12, $15, or $18/visit to $500 annual deductible,
Outpatient Drug / approved program; 50% of network allowance/ $20/visit; max 60 $10/visit; max 60 $10/visit; max 60
$20/visit; max 60 visits
Alcohol Rehab unlimited when medically 30 visits/year. $250,000 visits visits visits
necessary (Value Options) lifetime max.
PRESCRIPTION DRUGS
Prescription Drugs
30 days retail: 30 days retail:
*Note: 3-tier system Mail order OR retail pharmacy, 30 day supply: $5, $15, or $30. Mail order 31-90 day supply: $5, $20, or $55. 30 days retail:
$10/$25/$40. 90 30 days retail: $10/$30/$50. 90 days
(generic, preferred brand- Pharmacy 31-90 day supply: $10, $30, or $60. *When you fill a prescription for a $5/$15/$35. 90 days
days mail order: $5/$15/$35. Mail mail order:
name drugs, and non- brand-name drug that has a generic equivalent you pay the non-preferred brand-name co-payment plus the mail order:
$20/$50/$80. Open order not available. $20/$60/$100. Open
preferred brand-name difference in cost between the brand-name drug and its generic equivalent. $15/$45/$105.
formulary. formulary
drugs)
MISCELLANEOUS
Centers of Excellence for No cost at designated
Cancer and/or Centers of Excellence. Basic Medical Contact carrier Contact carrier Contact carrier Contact carrier
Transplant Precertification required.
$10 or applicable
$20/30 day supply;
No cost. Call HCAP for 50% of HCAP network $20/item; 30 day pharmacy rider,
Diabetic Supplies $10/item $50/per item for a 90
participating providers. allowance. supply whichever is less. (30
mail-order suppyl
day supply)
No cost. Call HCAP for Limited out of network $10/visit up to 40
Home Health Care Contact carrier Contact carrier Contact carrier
participating providers. benefits available visits
Page 4
5 2008 Health Insurance
Co-payment Comparison Chart (Rochester Area)
Durable Medical No cost. Call HCAP for
50% of network allowance 20% coinsurance 20% coinsurance 50% coinsurance 20% coinsurance
Equipment participating providers.
E M P I R E P L A N
Blue Cross (Hospital) United HealthCare (Medical) Independent
Blue Choice Community Blue Preferred Care
Health
Network Out of Network Participating Provider Out of Network
Orthotics Paid in full Basic Medical 20% coinsurance 20% coinsurance No cost 20% coinsurance
Prosthetics Paid in full. Basic Medical 20% coinsurance 20% coinsurance No cost 20% coinsurance
Inpatient: no cost up
Inpatient: no cost; to 60 days. Inpatient: no cost up Inpatient: No cost up
Outpatient: $12, $15, or PT/OT: $12, $15 or Outpatient: $20/visit to 45 days. to 45 days. Inpatient: no cost,
Rehabilitative Care (PT,
$18/visit for PT $18/visit (MPN). Speech: 50% of network allowance. up to 90 days; PT, Outpatient: Outpatient: $15/visit unlimited; Outpatient:
OT, Speech)
following surgery or $12, $15 or $18/visit. Speech and OT, $10/visit; max 20 up to 2 consecutive $20/visit up to 30 visits
hospitalization $20/visit up to 30 visits. months
visits
Acupuncture: 10 $50 towards a wellness
Alternative Medicine:
Discount from network visits @ 50%. program, Acupuncture:
Nutrition, Acupuncture, Not covered Contact carrier Contact carrier
provider Alternative Medicine 50% coinsurance up to
Massage Therapy
discounts. 10 visits
Preventive: 20% $30/cleaning; 20%
discount at select discount on
Dental (preventive) Not covered Not covered Not covered Not covered
providers; free additional services at
second annual exam select providers
Page 5
6 2008 Health Insurance
Co-payment Comparison Chart (Rochester Area)
up to $1200 or $1500 per
up to $1200 or $1500 per $600 max every 3 $600/3 years for
aid per ear every 4 years
Hearing Aids aid per ear every 4 years years for children Not covered Not covered dependents through age
(every 2 years for
(every 2 years for children). under 19. 19
children).
E M P I R E P L A N
Blue Cross (Hospital) United HealthCare (Medical) Independent
Blue Choice Community Blue Preferred Care
Health
Network Out of Network Participating Provider Out of Network
$20/exam associated Discount from
$20/annual exam; $20
Vision (routine) Not covered Not covered with disease or participating $10/visit once/year.
for diagnostic exams
injury. providers
Page 6
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