Health Insurance Plan Comparison

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Cost Sharing - Member's Responsibility

	HMO BlueCare 10	BlueOptions 3766	Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500	Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500
	Partially Health Care Reform Compliant	Partially Health Care Reform Compliant	Health Care Reform Compliant	Health Care Reform Compliant
Deductible (DED) (Per Person/Family Aggregate)
In-Network	N/A	$600 / $1,800	$1,750 / NA	$3,500 / $3,500
Out-of-Network	N/A	Combined w/ INN	$5,000 / NA	$10,000 / $10,000
Coinsurance (BCBSF pays / Member pays)
In-Network	N/A	80% / 20%	80% / 20%	80% / 20%
Out-of-Network	N/A	70% / 30%	60% / 40%	60% / 40%
Out of Pocket Maximum (Per Person/Family Aggregate)
In-Network	Includes Pharmacy - $5,000 / $10,000	Includes Pharmacy - $6,000 / $12,000	$4,500 / NA	$6,850 / $9,000
Out-of-Network	Includes Pharmacy - N/A	Includes Pharmacy - Combined w/ INN	$9,000 / NA	$18,000 / $18,000

Medical / Surgical Care by a Physician

	HMO BlueCare 10	BlueOptions 3766	Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500	Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500
	Partially Health Care Reform Compliant	Partially Health Care Reform Compliant	Health Care Reform Compliant	Health Care Reform Compliant
Office Services
In-Network Family Physician	$35	$35	DED + 20%	DED + 20%
In-Network Specialist	$50	$50	DED + 20%	DED + 20%
Out-of-Network	Not Covered	DED + 30%	DED + 40%	DED + 40%
Physician Services at Hospital
In-Network	$0	DED + 20%	DED + 20%	DED + 20%
Out-of-Network	Not Covered	DED + 30%	INN DED + 20%	INN DED + 20%

Medical / Surgical Care at a Facility

	HMO BlueCare 10	BlueOptions 3766	Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500	Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500
	Partially Health Care Reform Compliant	Partially Health Care Reform Compliant	Health Care Reform Compliant	Health Care Reform Compliant
Inpatient Hospital Facility (per admit)
In-Network	$220 per day up to $1,100 per admission	Option 1: $900 Option 2: $1,650	Option 1: Ded + 20% Option 2: Ded + 25%	Option 1: Ded + 20% Option 2: Ded + 25%
Out-of-Network	Not Covered	$2,500	$500 PAD + DED + 40%	$500 PAD + DED + 40%
Outpatient Hospital Facility (per visit) (Surgical)
In-Network	$250	Option 1: $250 Option 2: $350	Option 1: Ded + 20% Option 2: Ded + 25%	Option 1: Ded + 20% Option 2: Ded + 25%
Out-of-Network	Not Covered	$350	DED + 40%	DED + 40%
Outpatient Hospital Facility (per visit) (Non-Surgical)
In-Network	$250	$150 + 20% (no DED)	Option 1: Ded + 20% Option 2: Ded + 25%	Option 1: Ded + 20% Option 2: Ded + 25%
Out-of-Network	Not Covered	Included with Surgical Services	DED + 40%	DED + 40%

Emergency and Urgent Care

	HMO BlueCare 10	BlueOptions 3766	Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500	Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500
	Partially Health Care Reform Compliant	Partially Health Care Reform Compliant	Health Care Reform Compliant	Health Care Reform Compliant
Emergency Room Facility (per visit) - If admitted as an inpatient from ER, the hospital will submit an inpatient hospital claim instead of an ER facility claim. ER Copay will not apply on the claim; only inpatient facility cost share will apply.
In-Network	$100	$150 + 20% (no DED)	DED + 20%	DED + 20%

Urgent Care Centers
In-Network	$35	$35	DED + 20%	DED + 20%
Ambulance
In-Network	$0	$35	DED + 20%	DED + 20%

Other Special Services

HMO BlueCare 10	BlueOptions 3766	Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500	Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500
Partially Health Care Reform Compliant	Partially Health Care Reform Compliant	Health Care Reform Compliant	Health Care Reform Compliant
Gastric Bypass
1 PBP	1 PBP	1 PBP	1 PBP
TeleMedicine Services
$10	$10	DED + Coin, Allowance Maximum $45	DED + Coin, Allowance Maximum $45

Prescription Drugs

	HMO BlueCare 10	BlueOptions 3766	Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500	Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500
	Partially Health Care Reform Compliant	Partially Health Care Reform Compliant	Health Care Reform Compliant	Health Care Reform Compliant
In-Network - Generic / Brand / Non-Preferred
Retail	$15 / $45 / $65 / $250	$15 / $45 / $65 /$250	DED	DED
Mail Order	$30 / $90 / $130	$30 / $90 / $130	DED	DED

Monthly premiums

HMO BlueCare 10	BlueOptions 3766	Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500	Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500
Partially Health Care Reform Compliant	Partially Health Care Reform Compliant	Health Care Reform Compliant	Health Care Reform Compliant
Employee (College paid)
$1001	$792	$458	$458
Employee + 1
$1001	$792	$401	$401
Employee + Family
$1647	$919	$458	$458

HSA Voluntary Employee Contributions

Employees enrolled in either the HSA Individual Plan or HSA Family Plan are eligible to make additional contributions into their health savings account. Employees wishing to make voluntary contributions to their HSA or make changes to their voluntary contribution amount should contact Human Resources to complete the Employee HSA Payroll Deduction form and return it directly to Human Resources in the R-Annex for processing.

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