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retiree-WNY-pre-65-options

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Western NY Medical Option Overview

Below is a high-level overview of the 2023 Western New York medical option for
non-Medicare eligible participants who retired before December 31, 2015​. For details, visit
the BCBS of Western NY website.

Plan Features

  BCBS of Western NY
Annual Deductible Network Non-network
Employee Only $500 $2,000
Employee + One/Family $1,000 $4,000
Out-of-Pocket (OOP) Maximum    
Employee Only $5,000 $10,000
Employee + One/Family $10,000 $20,000
Coinsurance/Copay Copay or coinsurance required for most services 50%
See plan summary for details

Covered Services

  BCBS of Western NY Network
 Service What You Pay
Outpatient  
Office visits $20 copay
Preventive care 100% covered
X-rays and lab work 10% 
Physical therapy
(combined with occupational and speech therapy)
10%; max 30 visits/calendar year
Chiropractor $20 copay for medically necessary treatment only
Vision Care
Eye examinations 100% covered every other year
Lenses Discounts available on lenses and frames at participating providers
Frames
Inpatient Hospital
Room and board 10% after deductible
Ancillary charges 10% after deductible​
Skilled Nursing
Skilled nursing facility 10% after deductible
Surgery
Inpatient 10% after deductible
Outpatient 10%
Cosmetic Covered when medically necessary
Maternity Care
Obstetrical visits 100% covered after $20 copay first visit  
Hospitalization 10%
Mental Health
Inpatient 10% after deductible
Outpatient 10% 
Alcohol / Chemical Dependency
Inpatient detox/rehab 10% after deductible
Outpatient detox/rehab 10%
Other Services
Ambulance 10% after deductible
Hospice care 10%
Home health care $20 copay/visit;
40 visits/year max
Durable medical equipment 50%
Emergency / Urgent Care
Emergency room 10% after deductible
Urgent care 10%

Prescription Drugs

  BCBS of Western NY
(provided through Express Scripts)
Services What You Pay
Retail (30-day supply)  
Generic $10 copay
Formulary brand $30 copay
Nonformulary brand $50 copay
Mail order (90-day supply)  
Generic $30 copay
Formulary brand $90 copay
Nonformulary brand $150 copay

 

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