CMU Medical Plan Comparison For 2006-2007

Staff and Temporary Faculty

Benefits PPO 1* PPO 2**  
Health Maintenance Exam (Routine AnnualPhysical) 100% of R/C, one per calendar year, includes chest x-ray, EKG and select lab procedures. Only covered In-Network. 100% of R/C, one per calendar year, includes chest x-ray, EKG and select lab procedures. Only covered In-Network.  
Gynecological Exam 100% of R/C, one per calendar year. Only covered In-Network. 100% of R/C, one per calendar year. Only covered In-Network.  
Pap Smear Screening - (Laboratory and pathology services) 100% of R/C. One per calendar year. Only covered In-Network. 100% of R/C. One per calendar year. Only covered In-Network.  
Well Baby & Child Care Covered-100% of R/C 6 visits, birth through 12 months 6 visits, 13 months through 23 months 2 visits, 24 months through 35 months 2 visits, 36 months through 47 months 1 visit per birth year, age 4 through 15
Only covered In-Network. 		Covered-100% of R/C 6 visits, birth through 12 months 6 visits, 13 months through 23 months 2 visits, 24 months through 35 months 2 visits, 36 months through 47 months 1 visit per birth year, age 4 through 15
Only covered In-Network 		 
Immunizations 100% of R/C, one per calendar year up through age 16. Only covered In-Network. 100% of R/C, one per calendar year up through age 16. Only covered In-Network.  
Fecal Occult Blood Screening 100% of R/C. One per calendar year. Only covered In-Network. 100% of R/C. One per calendar year. Only covered In-Network.  
Flexible Sigmoidoscopy Exam 100% of R/C. One per calendar year. Only covered In-Network. 100% of R/C. One per calendar year. Only covered In-Network.  
Prostate Specific Antigen (PSA) Screening 100% of R/C. One per calendar year. Only covered In-Network. 100% of R/C. One per calendar year. Only covered In-Network.  
Mammography Screening 100% of R/C after deductible for In-Network providers; 80% of R/C after deductible for Out-of-Network providers. One per calendar year, no age restrictions. 80% of R/C after deductible for In-Network providers; 60% of R/C after deductible for Out-of-Network providers. One per calendar year, no age restrictions.  
Office Visits - Non Routine $10 co-pay with In-Network providers; 80% of R/C after deductible with Out-of-Network providers must be medically necessary. $10 co-pay with In-Network providers; 60% of R/C after deductible with Out-of-Network providers must be medically necessary.  
Urgent Care Visits $10 co-pay with In-Network providers; 80% of R/C after deductible with Out-of-Network providers must be medically necessary. $10 co-pay with In-Network providers; 60% of R/C after deductible with Out-of-Network providers must be medically necessary.  
Hospital Emergency Room Covered - $50 copay, waived if admitted or for an accidental injury Covered - $50 copay, waived if admitted or for an accidental injury  
Ambulance Services - medically necessary 100% of R/C 80% of R/C after deductible  
Laboratory and Pathology 100% of R/C for In-Network services; 80% of R/C after deductible for Out-of-Network services. 80% of R/C for In-Network services; 60% of R/C after deductible for Out-of-Network services.  
Diagnostic Tests and X-Rays 100% of R/C for In-Network services; 80% of R/C after deductible for Out-of-Network services. 80% of R/C for In-Network services; 60% of R/C after deductible for Out-of-Network services.  
Therapeutic Radiology 100% of R/C for In-Network services; 80% of R/C after deductible for Out-of-Network services. 80% of R/C for In-Network services; 60% of R/C after deductible for Out-of-Network services.  
Maternity Services Provided by a Physician
Delivery and Nursery Care		 100% of R/C with In-Network providers;  80% of R/C after deductible with Out-of-Network providers. Law prohibits hospital to no less than 48 hrs for a vaginal delivery and 96 hrs for a caesarian delivery, if needed. 80% of R/C after deductible with In-Network providers;  60% of R/C after deductible with Out-of-Network providers. Law prohibits hospital to no less than 48 hrs for a vaginal delivery and 96 hrs for a caesarian delivery, if needed.  
Pre- and Post-Natal Care 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. 100% of R/C with In-Network providers 60% of R/C after deductible with Out-of-Network providers.  
Inpatient Hospital Care General Conditions (semi-private room, inpatient physician care, meals, special diets, general nursing care, intensive care units, drugs, equipment and supplies, etc.) 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. Unlimited days. Note: Nonemergency care must be rendered in a participating hospital. 80% of R/C with In-Network providers 60% of R/C after deductible with Out-of-Network providers. Unlimited days. Note: Nonemergency care must be rendered in a participating hospital.  
Inpatient Consultations 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. 80% of R/C with In-Network providers 60% of R/C after deductible with Out-of-Network providers.  
Chemotherapy 100% of R/C with In-Network providers 80% of R/C after deductible with out-of-network providers. 80% of R/C with In-Network providers 60% of R/C after deductible with Out-of-Network providers.  
Skilled Nursing Care- non-custodial care 100% of R/C up to 120 days per calendar year. 80% of R/C after deductible up to 120 days per calendar year  
Hospice 100%, covers up to 210 days for 2 - 90 day periods and 1 - 30 day period during the patient's lifetime. Not subject to co-pay or deductibles. Payable up to lifetime max of $15,916.00 of which $1,104.59 is the max for physician's charges outside of the hospice team. Note: subject to yearly upgrades set by the state. 100%, covers up to 210 days for 2 - 90 day periods and 1 - 30 day period during the patient's lifetime. Not subject to co-pay or deductibles. Payable up to lifetime max of $15,916.00 of which $1,104.59 is the max for physician's charges outside of the hospice team. Note: subject to yearly upgrades set by the state.  
Home Health Care 100% of R/C, unlimited days. 80% of R/C after deductible, unlimited days  
Surgery - includes related surgical services 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. Multiple surgeries through the same incision - they pay the amount of the highest cost surgery; but there are some surgeries that they do pay half of the other surgery. Note: if using a participating doctor, payment in full will be accepted (should be checked with customer service for more details). 80% of R/C after deductible with In-Network providers 60% of R/C after deductible with Out-of-Network providers. Multiple surgeries through the same incision - they pay the amount of the highest cost surgery; but there are some surgeries that they do pay half of the other surgery. Note: if using a participating doctor, payment in full will be accepted (should be checked with customer service for more details).  
Voluntary Sterilization 100% of R/C with In-Network providers 80 of R/C after deductible with Out-of-Network providers. 80% of R/C after deductible with In-Network providers 60% of R/C after deductible with Out-of-Network providers.  
Human Organ Transplants
Specified Organ Transplants, when coordinated through BCBSM Human Organ Transplant Program (1-800-242-3504)		 100% of R/C - approved facilities only, $1 million per covered transplant. 100% of R/C - approved facilities only, $1 million per covered transplant.  
Bone Marrow - when coordinated through BCBSM Human Organ Transplant Program (1-800-242-3504); specific criteria applies 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. 80% of R/C after deductible with In-Network providers 60% of R/C after deductible with Out-of-Network providers.  
Inpatient Mental Health Care (in an approved facility) 80% of R/C with In-Network providers; 80% of R/C after deductible with Out-of-Network providers. Unlimited days. 80% of R/C after deductible with In-Network providers; 80% of R/C after deductible with Out-of-Network providers. Unlimited days.  
Inpatient Substance Abuse Treatment - (in an approved facility) 80% of R/C with In-Network providers; 80% of R/C after deductible with Out-of-Network providers. 80% of R/C after deductible with In-Network providers; 80% of R/C after deductible with Out-of-Network providers.  
Outpatient Mental Health Care - approved facility* - physicians** charges Facility and Clinic: 80% of R/C Physician's Office: 80% of R/C** Facility and Clinic: 80% of R/C after deductible
Physician's Office: 80% of R/C after deductible**		  
*Because of the HIPAA ruling, no annual or lifetime maximums at this time.
**Needs to be seen by a fully licensed Psychologist or Psychiatrist - no social workers or limited licensed psychologists.
Outpatient Substance Abuse Treatment - in an approved facility 80% of R/C up to the minimum amount mandated by state law for outpatient and residential substance abuse treatment. 80% of R/C up to the minimum amount mandated by state law for outpatient and residential substance abuse treatment.  
Allergy Testing/Therapy 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. 100% of R/C with In-Network providers 60% of R/C after deductible with Out-of-Network providers.  
Chiropractic care Chiropractic manipulation: covered at 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. Up to 24 visits per calendar year. Chiropractic manipulation: 100% of R/C with In-Network providers 60% of R/C after deductible with Out-of-Network providers. Up to 24 visits per calendar year.  
Physical Therapy
Facility And Clinic		 100% of R/C with In-Network providers 100% of R/C with Out-of-Network providers. Limited to a combined 60 visits per calendar year for physical therapy in the outpatient department of a hospital as well as in the physician's office. 80% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. Limited to a combined 60 visits per calendar year for physical therapy in the outpatient department of a hospital as well as in the physician's office.  
Physical Therapy
Physician's Office		 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. Limited to a combined 60 visits per calendar year for physical therapy in the outpatient department of a hospital as well as in the physician's office. 80% of R/C with In-Network providers 60% of R/C after deductible with Out-of-Network providers. Limited to a combined 60 visits per calendar year for physical therapy in the outpatient department of a hospital as well as in the physician's office.
Durable Medical Equipment 100% of R/C 80% of R/C after deductible  
Prosthetic and Orthotic Appliance (accredited provider required for custom made appliances) 100% of R/C 80% of R/C after deductible  
Private Duty Nursing 50% of R/C 50% of R/C after deductible
Cardiac Rehabilitation 100% Coverage in Phase I & II (within 90 days of event);80% coverage with Out-of-Network providers after $250 per person/$500 per family deductible. 80% Coverage in Phase I & II (within 90 days of event) after $250 per person/$500 per family deductible; 60% coverage with Out-of-Network providers after $500 per person/$1000 per family deductible.  
Prescription Drugs Covered under a separate provider, Express Scripts Covered under a separate provider, Express Scripts  
Vision Therapy Not covered Not covered  
Payment of Benefits Participating Hospitals: 100% of covered benefits Preventative Services: Only a benefit In-Network Non-PPO Providers: Without a referral will require you to pay a 20% copay. Care with a referral may result in you being billed the difference between our approved amount and the provider's charge. Participating Hospitals: 80% of covered benefits Preventative Services: Only a benefit In-Network Non-PPO Providers: Without a referral will require you to pay a 40% copay. Care with a referral may result in you being billed the difference between our approved amount and the provider's charge.  
Deductibles, Co-pays and Benefit Maximums Deductible: In-Network: None Out-of-Network: $250 per member, $500n per family, per calendar year. Co-payments: Fixed: $10 office visits, $50 Emergency Room Percent In-Network:None for general services, 20% mental health and substance abuse care, 50% co-pay for private duty nursing. Percent Out-of-Network: 20% for general services up to annual out-of-pocket maximum, 20% mental health. 50% private duty nursing. (Services without a network are covered at in-network level.) Annual out-of-pocket Maximums: In-Network:None Out-of-Network: $2,000 per member, $4,000 per family, excludes mental health and private duty nursing. Lifetime Benefit Maximums: $1 million lifetime per covered specified human organ transplant type and a separate $5 million lifetime per member for all other covered services and a noted above for individual services. Deductible: In-Network: $250 per member, $500 per family, per calendar year. Out-of-Network:$500 per member, $1,000 per family, per calendar year. Co-payments: Fixed: $10 office visits, $50 Emergency Room Percent In-Network:20% copay for general services, 20% copay for mental health and substance abuse care, 50% copay for private duty nursing. Percent Out-of-Network:40% for general services up to annual out-of-pocket maximum, 20% mental health, 50% private duty nursing. without a network are covered at in-network level.) Annual out-of-pocket Maximums: In-Network:$1,000 per member, $2,000 per family per calendar year Out-of-Network:$3,000 per member, $6,000 per family per family per calendar year, excludes mental health and private duty nursing. Lifetime Benefit Maximums:  $1 million lifetime per covered specified human organ transplant type and a separate $5 million lifetime per member for all other covered services and a noted above for individual services.