Plan Name

BC/BS/OMM

(Represented)

BC/BS/OMM

(Coatesville)

(Represented)

BC/BS/MM - RR

(Represented)

Member Services 

Number

1-800-345-3131

www.bluecares.com

1-800-345-3131

www.bluecares.com

1-800-345-3131

www.bluecares.com

Individual Lifetime 

Maximum Benefits

$100,000 Major Medical

$100,000 Major Medical

$50,000 Major Medical

Individual Annual Deductible

$75

$75 Non-Medicare; $0 Medicare

$75

Family Annual Deductible

$150

$150 Non-Medicare; $0 Medicare

$150

Coinsurance

20% - Major Medical

20% - Major Medical

20% - Major Medical

Individual Out-of-Pocket Maximum Per Year

None

None

None

Family Out-of-Pocket Maximum Per Year

None

None

None

Precertification

Patient Responsibility

Patient Responsibility

Patient Responsibility

Claims Filing

Yes

Yes

Yes

Inpatient Hospital

100% up to 120 days per calendar year

100% up to 120 days per calendar year

100% up to 120 days per calendar year

Physicians Services: PCP Office Visit

80% after MM deductible

80% after MM deductible

80% after MM deductible

Emergency Care: In-area Hospital

100% Emergency Accident Only

100% Emergency Accident Only

100% Emergency Accident Only

Outpatient X-Ray and Lab

100%  up to $75 per calendar year

100% up to $300 per calendar year

100% up to $75 per calendar year

Prescription Coverage: Generic Drug Copay

10%**

10%**

10%

Prescription Coverage: Brand Name Drug Copay

20%**

20%**

20%

Prescription Coverage: Mail Order Copay

10% Generic; 20% Brand

$5 Generic**;$15 Brand**

10% Generic; 20% Brand

Diabetic Benefits: Chem. Strips/Lancets

Covered under Pharmacy Benefit

Covered under Pharmacy Benefit

Covered under Pharmacy Benefit

Home Health Care

80% after deductible up to 100 days per year

80% after deductible up to 100 days per year

80% after deductible up to 100 days per year

Durable Medical Equipment and Maximum

80% after MM deductible

80% after MM deductible 

80% after MM deductible 

Mental Health: Inpatient Benefit and Maximum

100% up to 30 days per 12 month period

100% up to 30 days per 12 month period

100% up to 30 days per 12 month period

Mental Health: Outpatient Benefit and Maximum

80% after MM Deductible

80% after MM Deductible

80% after MM Deductible

Substance Abuse: Inpatient Benefit and Maximum

Not Covered

Not Covered

Not Covered

Substance Abuse: Outpatient Benefit and Maximum

Not Covered

Not Covered

Not Covered

Vision Care: routine Eye Exam

Not Covered

Not Covered

Not Covered

Vision Care: Eye Glasses and Contact Lenses

Not Covered

Not Covered

Not Covered

Hearing Care: Exam

Provided by National Ear Care Plan (NECP)

1-800-999-1458

Provided by National Ear Care Plan (NECP)

1-800-999-1458

Provided by National Ear Care Plan (NECP)

1-800-999-1458

Hearing Care: Hearing Aids

Provided by National Ear Care Plan (NECP)

1-800-999-1458

Provided by National Ear Care Plan (NECP)

1-800-999-1458

Provided by National Ear Care Plan (NECP)

1-800-999-1458

Dental Care: Basic Services

Not Covered

Not Covered

Not Covered

Dental Care: Major Services

Not Covered

Not Covered

Not Covered

Dental Care Preventive Services

Not Covered

Not Covered

Not Covered

Wellness Benefits

Mammograms, pap smear and PSA tests - 80% after MM deductible

Mammograms, pap smear and PSA tests - 80% after MM deductible

None

*Foot notes

*The mental Health and Substance Abuse Benefits for Burns Harbor, Pennsylvania Steel Technologies, Sparrow Point and Conshohocken are administered by a separate Third Party Administrator and the benefits may be different then stated above.

**For retirement on and after 8/31/99 -- prescription drug copays are 15% generic; 25% brand; Mail Order -- copays 10% generic; 20% brand

**For retirement on and after 8/31/99 -- prescription drug copays are 15% generic; 25% brand; Mail Order -- copays 10% generic; 20% brand