> ]_\ j5bjbj 3pQ,LL8Od ??"aaa #"aa9@@@Raa@@@"@aR@0 @[$[$@[$@T@v [$L U: Le Moyne College Benefit Comparison 2011
BluePPO Option J:
InNetwork Care rendered by a participating BlueCross BlueShield PPO provider. No PCP referral required.
OutNetwork Care rendered by a nonparticipating BlueCross BlueShield provider.
Healthy Blue:
InNetwork Care rendered by a participating BlueCross BlueShield PPO provider. No PCP referral required.
OutNetwork Care rendered by a nonparticipating BlueCross BlueShield provider.
Benefit Category BluePPO HealthyBlue
Hospital/Facility Inpatient:
SemiPrivate Room and Board InNetwork  Covered in Full InNetwork Covered, subject to deductible and 20% coins
OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Skilled Nursing Facility InNetwork  Covered in Full InNetwork Covered, subject to deductible and 20% coins
Out  Network Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
(Up to 120 days) (Up to 45 days)
Emergency Services:
Emergency Room InNetwork  $50 Copayment InNetwork  $250 Copayment
OutNetwork  $50 Copayment OutNetwork $250 Copayment
Freestanding Urgent Care InNetwork  $25 Copayment InNetwork  $40 Copayment
OutNetwork Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Ambulance InNetwork $20 Copayment InNetwork $250 Copayment
OutNetwork  $20 Copayment OutNetwork  $250 Copayment
Outpatient Hospital/Facility:
Diagnostic Xray Services InNetwork  $20 Copayment InNetwork $40 Copayment
OutNetwork  Covered, subject to deductible OutNetwork  Cov ered, subject to deductible and 40% coins
and 30% coinsurance
Diagnostic Laboratory InNetwork  Covered in Full InNetwork Covered in Full
And Pathology Services OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Outpatient Surgery InNetwork  $20 Copayment InNetwork  Covered, subject to deductible and 20% coins
OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
PreSurgical Testing InNetwork  Covered in Full InNetwork Covered in Full
OutNetwork  Covered, subject to deductible OutNetwork Covered, subject to deductible and 40% coins
and 30% coinsurance
Benefit Category BluePPO HealthyBlue
Physicians Inpatient Services:
Surgery InNetwork Covered in Full InNetwork Covered, subject to deductible and 20% coins
OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Anesthesia InNetwork Covered in Full InNetwork Covered, subject to deductible and 20% coins
OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 20% coins
and 30% coinsurance
InHospital Daily Visits InNetwork Covered in Full InNetwork Covered, subject to deductible and 20% coins
OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Physicians Office:
Medical Office Care InNetwork  $20 Copayment InNetwork  $25 Copayment for PCP, $0 Copayment to age 19
OutNetwork Covered, subject to deductible $40 Copayment for Specialist
and 30% coinsurance OutNetwork  Covered, subject to deductible and 40% coins
Adult Routine Physical InNetwork  Covered in full InNetwork Covered in full
(Annual) OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Routine GYN Exams InNetwork Covered in full InNetwork Covered in full
(Once per year) OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Pap Smear and Mammogram InNetwork Covered in full InNetwork Covered in full
Screening OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Well Child Care InNetwork Covered in full InNetwork Covered in full
OutNetwork Covered in full OutNetwork Covered in full
Allergy Testing InNetwork  $20 Copayment InNetwork  $25 Copayment for PCP, $0 Copayment to age 19
OutNetwork  Covered, subject to deductible $40 Copayment for Specialist
and 30% coinsurance OutNetwork  Covered, subject to deductible and 40% coins
Allergy Treatment InNetwork Covered in full InNetwork  $25 Copayment for PCP, $0 Copayment to age 19
OutNetwork Covered, subject to deductible $40 Copayment for Specialist
and 30% coinsurance OutNetwork  Covered, subject to deductible and 40% coins
Maternity:
Hospital Charge for Mother InNetwork  Covered in Full InNetwork Covered, subject to deductible and 20% coins
OutNetwork Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Physician Delivery Charge InNetwork  Covered in Full InNetwork Covered, subject to deductible and 20% coins
OutNetwork Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Prenatal/Postnatal Office Visits InNetwork  $20 Copayment for 1st visit InNetwork Covered, subject to deductible and 20% coins
OutNetwork Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Newborn Nursery Care InNetwork  Covered in Full InNetwork Covered in full
OutNetwork Covered, subject to deductible OutNetwork  Covered, subject to 40% coinsurance
and 30% coinsurance
Benefit Category BluePPO HealthyBlue
Psychiatric and Chemical Dependence:
Inpatient Mental Care InNetwork  Covered in Full InNetwork Covered, subject to deductible and 20% coins
OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Inpatient Detoxification and InNetwork  Covered in Full InNetwork Covered, subject to deductible and 20% coins
Chemical Dependence OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Outpatient Mental Care InNetwork  $20 Copayment InNetwork $40 Copayment
OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Outpatient Chemical Dependence InNetwork  $20 Copayment InNetwork $40 Copayment
OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Other Services:
Chiropractic Care InNetwork  $20 Copayment InNetwork $40 Copayment
OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Physical Therapy (combined InNetwork  $20 Copayment InNetwork $40 Copayment
with speech, respiratory and OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
occupational therapy) and 30% coinsurance (up to 45 visits)
(up to 45 visits)
Diabetic Supplies InNetwork  $20 Copayment InNetwork $25 Copayment
OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Durable Medical Equipment/ InNetwork  Covered, subject to 20% coins InNetwork Covered, subject to deductible and 20% coins
Prosthetics OutNetwork  Covered, subject to deductible OutNetwork  Covered, subject to deductible and 40% coins
and 30% coinsurance
Hospice Care InNetwork  Covered in Full InNetwork Covered in Full
OutNetwork  Covered, subject to deductible OutNetwork Covered, subject to 40% coinsurance
and 30% coinsurance
Home Health Care InNetwork Covered in Full InNetwork Covered, subject to deductible and 20% coins
OutNetwork Covered, subject to $50 ded OutNetwork  Covered, subject to $50 ded and 25% coins and 25% coinsurance (40 visits)
Routine Vision Care Not covered InNetwork $40 Copayment
OutNetwork Covered, subject to deductible and 40% coinsurance
(1 visit per calendar year)
Prescription Drugs Retail (30 day supply): Retail (30 day supply):
Tier 1  $10 Copayment Tier 1 Tier 1  $5 Copayment ($0 Copayment to age 19) Tier 2  $30 Copayment Tier 2* Tier 2  $35 Copayment *
Tier 3  $50 Copayment Tier 3* Tier 3  $70 Copayment *
Mailorder (90 day supply): Mailorder (90 day supply):
Tier 1  $20 Copayment Tier 1  $10 Copayment ($0 Copayment to age 19)
Tier 2  $60 Copayment * Tier 2  $70 Copayment *
Tier 3  $100 Copayment * Tier 3  $140 Copayment *
Benefit Category BluePPO HealthyBlue
Calendar Year Deductible InNetwork  None Combined InNetwork and OutNetwork:
OutNetwork $750 Individual/ $250 Individual/ $750 Family
$2,250 Family
Coinsurance InNetwork  None InNetwork 20%
OutNetwork 30% OutNetwork  40%
Annual Out of Pocket Maximum InNetwork  None Combined InNetwork and OutNetwork:
(Includes Ded and Coins and OutNetwork  $2,000 Individual/ $750 Individual/ $2,250 Family
does not include copayments) $6,000 Family
Lifetime Maximum Unlimited Unlimited
Dependent Coverage Covers spouse and qualified dependents and Covers spouse and qualified dependents and
students to age 26 students to age 26
*Should a doctor choose a brandname drug when an FDAapproved generic equivalent is available, the benefit will be based on the generic drugs cost and the member will have to pay the difference, plus any applicable Copayment. If a brandname prescription has no approved generic equivalent, the benefit wont be affected.
Updated October 2010
PAGE
PAGE 4
*Any contract changes have been indicated in bold print.*
This outline of benefits is for illustrative purposes, only.
Official benefits, limitations and exclusions contained in actual contract.
&(:< K O W X s
7
B
c
w
/0JUv
ü۵
h\CJ
hkJ1CJh\h\5CJh\h?35CJ
hjCJ
h?3CJ
h?35CJ
hM5CJ
h{5CJ
h ?05CJ h=5 h`65
h?35CJ hM5 h?35 h*U5
h*U5CJ
h?35CJ6)*< t
01 @^@`
$dNgd*U)$$d%d&d'dNOPQa$gd*U3[
B
G
()p/ p^p`
&dP@^@@^@`gd\ @^@`25FJ[
3
4
a
l
o
p
r
')5@CQ`ot軱軱ű豻űű蠚
hG;CJhG;hG;5CJ
hu/5CJhu/hu/5CJhu/h?35CJ
hu/CJ
hCJ
hkJ1CJ
h?35CJh\h?35CJ
h?3CJ
h\5CJh\h\5CJ9!4BR`/=P['+9Wɿӿ幯幥幯幛幯h9h?3CJ
hP5CJhPh?35CJhPhP5CJh\hP5CJhG;hP5CJ
hPCJhGhG5CJhGh?35CJ
hGCJ
hkJ1CJ
hG;CJ
h?3CJhG;hG;5CJhG;h?35CJ1/(
$dN
&dP ^``*+IJ{~#%01^dryoe_y
hgv^CJhGhYa5CJhYahYa5CJhYah?35CJheh?3CJ
hYaCJ
hkJ1CJ
h?3CJ
hW 5CJ
h\5CJ
h?35CJ
h/5CJ
h?35CJh9h?35CJh9h95CJhG;h95CJ
h9CJh9hPCJh9h?3CJh9hkJ1CJ%_ex./cd?bgdz @^@`@&dP^@`gdF*+6dx>Iw.BCDOPSTUȾѴȮȥѾȾѴȮțѾ~t~h{Qh{Q5CJh{Qh?35CJ
hkJ1CJ
hW CJ
h?35CJhF*hF*5CJhF*hF*CJ
hgv^CJhGhF*5CJhYahF*5CJhehF*CJ
hF*CJhYah?5CJhYahYa5CJ
hYaCJ
h?3CJheh?3CJUmpqr&(YZ\c"#%DNabvȾȭ旧Ⱦȭh2hz5CJh2h25CJh{Qhz5CJ
hkJ1CJ
hzCJhYah{Q5CJ
h{Q5CJhGh{Q5CJ
h{QCJ
hW CJ
hgv^CJ
h`6CJ
ha=CJh{Qh{Q5CJh{Qh?35CJ
h?3CJ3bcNO;<5i(@&dP^@` @^@`^`gd2gd2 ^`#$&/:Mh':;<=LW +49Gef}7:;<O
hgv^CJh?35>*CJ
hW CJ
h^;CJ
hkJ1CJhYah25CJh2h?35CJh2h25CJhGh25CJ
h2CJ
h?3CJ
h CJ@OT_hjx(DEPq*+,Gt{ukuh\hk)5CJ
hk)CJhYahC5CJhCh?35CJhChC5CJhGhC5CJh\hC5CJ
hkJ1CJ
hCCJ
h?35CJhYah25CJh2h25CJh2h?35CJhGh25CJ
h2CJ
h?3CJ
hgv^CJ
hzCJ&(),/2# G [!!!!!!!
&dPgdq)Z@^@`gdgd@^@`gdk)gdk)gdC @^@`/1Sauw} 2 E G
!(!K!L!N!\!t!!!!!!!!ɿɩɟɕɋυɟϿ{ɋtmfm
h\5CJ
h?35CJ
h?35CJhh?35CJ
hkJ1CJhYah5CJhCh5CJhGh5CJh\h5CJhh5CJH*hh5CJ
hCJ
h?3CJ
h?CJhYahk)5CJhChk)5CJ
hk)CJhGhk)5CJ&!!!!!
"!"M"y""""""##3#8#:#f####$$$D$^$l$o$$$$$$%%,%L%Z%]%x%{%%%%%&&&.&B&P&S&n&q&&&&&&'!','.'<'?'ǽǽǽǽǽǽǽǽǽǽݷݧݷ
h9CJhG;h{5CJ
h{CJhG;h5CJ
hCJh\htj5CJ
htjCJ
h?3CJ
h*=<5CJ
h?35CJ
h?35CJ
hh85CJB!!! "
"{""###$D$E$F$$%,%%%%&&&&&
&dPgd ^`gdtj
$dN&.&&&''k''=(W(X(():)?))7*Z*[** +++,++0,8,,@^@`gdh8 @^@`gd{?'Z']'k'''''''((((+(<(=(B(S(V(W(X(l(z(}(((((())&):)[)f)i)p))))))))))*.*0*<*F*Y*Z*[*h*s**
h?35CJh{h{5CJh{h?35CJ
hkJ1CJ
h{5CJ
h?3CJh9h?35CJh9h95CJh9h{CJh9h9CJ
h95CJ
h9CJhG;h{5CJ
h{CJ8****** ++*+++,+?+J+k++++++++++++,,, ,!,$,7,8,L,Z,k,l,n,,,,,,,,,,,,깯ꥯ깯꜖ꖌꖹ
h`6CJhjbhh85CJ
hh8CJh?35>*CJhjbh?35CJhjbhjb5CJ
hjbCJh\h{5CJ
hkJ1CJ
h?35CJh{h?35CJh{h{5CJ
h?3CJhG;h{5CJ
h{CJ0,,,,8..G.../////?///g0h0gd_
$dNgdgpgdgpgdcgdp^p`gdp^p`gd,$%578AXabco...5.6.G.P.պͯկկwnպh5CJaJhB5CJaJhhh85CJaJhh5CJaJhh?35CJaJh,hh8CJaJh,h?3CJaJhCJaJh,haCJaJha=CJaJh,hCJaJhn5CJaJhch?35CJaJhnh?3CJaJ*P.Q.R.W.^._.b.k.l.n.y...................../////)/+/.///://}vo
hh85CJ
h*=<5CJ
h\5CJ
hgp5CJ
hgp5CJ
htj5CJh,hcCJhhc5CJhB5CJaJhhh85CJaJha=CJaJh,hh8CJaJh,hCJaJhCJaJhh5CJaJhh5CJaJ*>/Y/j/n/////////////0"0/0e0f0v000000000000000000"1#1f1g1ǠǠ~rh#(ha5CJaJh#(h?35CJaJh#(h#(5CJaJh#(h#(5CJhFFh?35CJ
hkJ1CJ
h_5CJhFFh_5CJ
hFFCJhFFhFF5CJ
hFF5CJ
h_CJhFFh#(5CJh#(hFF5CJaJ
h#(CJ
h?3CJ*h00000g11222.222222222444444444@^@`gdag1h11111111111112222 2T2h2m2222222222224״ͪפ~tm~dhih ?0CJ
h ?05CJh,hh85CJ
h_CJhih ?05CJ
h ?0CJh\h ?05CJ
hiCJ
h?3CJh#(h?35CJ
h#(5CJh#(h#(>*CJhaCJaJh#(h#(5CJ
h#(CJ
ha5CJh#(5CJaJh#(h#(CJaJ
h#(5CJ!4484B4D4Q4R4T4U4W4X4Z4[4]4^4d4e4f4h4i4o4p4q4r4s444444b5f5h5i5j5ʵԪh?3
h_CJ
h_CJ h_5hB0JmHnHuh_
h_0Jjh_0JUhujhuU
h ?0CJ
h`6CJ
h?3CJjh?3UmHnHu"4444 4!4"4#4$4%4&4'4(404E4F4G4H4I4J4K4L4M4N4O4P4Q4S4T4V4V4W4Y4Z4\4]4f4g4h4s444445d5e5f5g5h5i5j5$a$h`h&`#$1
0:pgv^/ =!"h#@$%^2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH 8`8Normal_HmH sH tH DA`DDefault Paragraph FontViVTable Normal :V44
la(k (No List6B@6 Body Text5CJ44Header
!4 @4Footer
!.)@!.Page NumberPK![Content_Types].xmlj0Eжr(Iw},j4 wPt#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu*Dנz/0ǰ$X3aZ,D0j~3߶b~i>3\`?/[G\!Rk.sԻ..a濭?PK!֧6_rels/.relsj0}Q%v/C/}(h"O
= C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xmlM
@}w7c(EbˮCAǠҟ7՛K
Y,
e.,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+&
8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuرMniP@I}úama[إ4:lЯGRX^6؊>$!)O^rC$y@/yH*)UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\ʜ̭NleXdsjcs7f
W+Ն7`gȘJjh(KD
dXiJ؇(x$(:;˹!I_TS1?E??ZBΪmU/?~xY'y5g&/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ
x}rxwr:\TZaG*y8IjbRcXŻǿI
u3KGnD1NIBs
RuK>V.EL+M2#'fi~Vvl{u8zH
*:(W☕
~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4=3ڗP
1Pm\\9Mؓ2aD];Yt\[x]}Wr]g
eW
)6rCSj
id DЇAΜIqbJ#x꺃6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP8քAV^f
Hn"d>znǊ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QDDcpU'&LE/pm%]8firS4d7y\`JnίIR3U~7+#mqBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCMm<.vpIYfZY_p[=alY}Nc͙ŋ4vfavl'SA8*u{ߟ0%M07%<ҍPK!
ѐ'theme/theme/_rels/themeManager.xml.relsM
0wooӺ&݈Э5
6?$Q
,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}$b{P8g/]QAsم(#L[PK![Content_Types].xmlPK!֧6+_rels/.relsPK!kytheme/theme/themeManager.xmlPK!Ptheme/theme/theme1.xmlPK!
ѐ' theme/theme/_rels/themeManager.xml.relsPK]
jj
p UO!?'*,P.>/g14j5!#$&')*.01245/b(!&,h04V4j5 "%(+,/367 !!8
@
(
V
#"?
B
S ?,j$T*1
##&&,&5&&&$'+'/':'r)u)Q,Q,S,S,T,T,V,W,Y,Z,\,],,,kMW"dn8B
GQNQy:=ku'*OYHRKUV`25tw 03akOY EO$koC E o y &!)!^!h!F"I"k"u"##B#L#&
'))))**++Q,Q,S,S,T,T,V,W,Y,Z,\,],,,k33333333333333333333333333333333333333333333333333333333333333mm*
I
{

+T_!%%3899:D^,L..B!,.W X X l :!p!!!!!!"."<"Z""""""" #+#k##!$$$%%&&''.'/'''''''("(f(f(****P,Q,Q,S,S,T,T,V,W,Y,Z,\,],e,h,r,,gghkmm %%&&/':'kON#(2,>;7vM\P,Bn W F*,Hu/ ?0
B0kJ1?3Z5`6h8^;C#<*=<MAHKM{QeTq)Zgv^Yajbtjui1z7XL{zZVfa=_cj/=*U?`weG;PC{lFF} 9{aGgpk)MQ,S,@jP@UnknownG* Times New Roman5Symbol3.* ArialA BCambria Math"1h.ꆉ%P%P!4d;,;,2QHP ?2!xx(Le Moyne College Benefit Comparison 2004Terry Brislin  MarketingmessindeOh+'0, @L
lx
,Le Moyne College Benefit Comparison 2004Terry Brislin  MarketingNormalmessinde3Microsoft Office Word@xA@ԮGq@?@ABCDEFGHIJKMNOPQRSUVWXYZ[^Root Entry FZ`1Table9[$WordDocument3pSummaryInformation(LDocumentSummaryInformation8TCompObjy
F'Microsoft Office Word 972003 Document
MSWordDocWord.Document.89q