2017 MONTEPRIME EPO – MONTECARE PPO MEDICAL COMPARISON
INDIVIDUAL/FAMILY DEDUCTIBLE
Montefiore Network
MontePrime EPO – None
MonteCare PPO – None
Empire BlueCard PPO Network
MontePrime EPO – None
MonteCare PPO – $500/$1,000
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – $1,000/$2,500
INDIVIDUAL/FAMILY OUT-OF-POCKET MAXIMUM (DEDUCTIBLE + COPAYMENT + COINSURANCE)
Montefiore Network
MontePrime EPO – $6,100/$12,200
MonteCare PPO – $5,350/$10,700
Empire BlueCard PPO Network
MontePrime EPO – $6,100/$12,200
MonteCare PPO – $5,350/$10,700
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – $6,000/$17,500
INPATIENT CARE
* HOSPITALIZATION – ILLNESS OR INJURY
* MENTAL HEALTH/SUBSTANCE ABUSE CARE
* PHYSICAL/OCCUPATIONAL THERAPY OR REHAB
Montefiore Network
MontePrime EPO – $0
MonteCare PPO – $0
Empire BlueCard PPO Network Preferred Facility
MontePrime EPO – Not covered except in the case of an emergency
MonteCare PPO – $1,000 copay if precertified by Conifer Value Based Care; otherwise $1,500 copay
Empire BlueCard PPO Network Non-preferred Facility
MontePrime EPO – Not covered except in the case of an emergency
MonteCare PPO – $2,000 copay if precertified by Conifer Value Based Care; otherwise $2,500 copay
Out-of-network
MontePrime EPO – Not covered except in the case of an emergency
MonteCare PPO – 40%2 coinsurance after $1,000 copay if precertified by Conifer Value Based Care; otherwise $1,500 copay
HOSPICE – 210 DAYS
Montefiore Network
MontePrime EPO – $0
MonteCare PPO – $0
Empire BlueCard PPO Network
MontePrime EPO – $0
MonteCare PPO – $0
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – 30%2 coinsurance after deductible
SKILLED NURSING FACILITY – 120 DAYS
Montefiore Network
MontePrime EPO – $0
MonteCare PPO – $0
Empire BlueCard PPO Network
MontePrime EPO – $0
MonteCare PPO – $0
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – 30%2 coinsurance after deductible
EMERGENCY ROOM IN A BONA FIDE EMERGENCY
Montefiore Network
MontePrime EPO – $50 copay (waived if admitted)
MonteCare PPO – $100 copay (waived if admitted)
Empire BlueCard PPO Network
MontePrime EPO – $50 copay (waived if admitted)
MonteCare PPO – $100 copay (waived if admitted)
Out-of-network
MontePrime EPO – $50 copay (waived if admitted)
MonteCare PPO – $100 copay (waived if admitted)
EMERGENCY ROOM OTHER THAN A BONA FIDE EMERGENCY
Montefiore Network
MontePrime EPO – Not covered
MonteCare PPO – 30%1 coinsurance after deductible
Empire BlueCard PPO Network
MontePrime EPO – Not covered
MonteCare PPO – 30%1 coinsurance after deductible
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – 30%2 coinsurance after deductible
URGENT CARE FACILITY
Montefiore Network
MontePrime EPO – $0
MonteCare PPO – $0
Empire BlueCard PPO Network
MontePrime EPO – $50 copay/visit
MonteCare PPO – $30 copay/visit
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – 30%2 coinsurance after deductible
URGENT CARE PROFESSIONAL
Montefiore Network
MontePrime EPO – $0
MonteCare PPO – $15 copay/visit
Empire BlueCard PPO Network
MontePrime EPO – $50 copay/visit
MonteCare PPO – $30 copay/visit
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – 30%2 coinsurance after deductible
PREVENTIVE CARE
* ROUTINE PHYSICAL EXAM WITH PCP INCLUDING OB/GYN
* ROUTINE WELL CHILD EXAMS/IMMUNIZATIONS
* ROUTINE MAMMOGRAPHY
Montefiore Network
MontePrime EPO – $0
MonteCare PPO – $0
Empire BlueCard PPO Network
MontePrime EPO – $0
MonteCare PPO – $0
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – 30%2 coinsurance after deductible
OUTPATIENT DIAGNOSTIC AND LABORATORY TESTS
* X-RAYS, BONE DENSITY, BLOOD, URINE
Montefiore Network
MontePrime EPO – $0
MonteCare PPO – $0
Empire BlueCard PPO Network
MontePrime EPO – Not covered
MonteCare PPO – 10%1 coinsurance after deductible
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – 30%2 coinsurance after deductible
HIGH-TECH RADIOLOGY SERVICES
(INCLUDE, BUT NOT LIMITED TO DIAGNOSTIC MRI, MRA, CAT SCAN, PET, NUCLEAR CARDIOLOGY)
Montefiore Network
MontePrime EPO – $0
MonteCare PPO – $0
Empire BlueCard PPO Network Preferred Facility
MontePrime EPO – Not covered
MonteCare PPO – $250 copay
Empire BlueCard PPO Network Non-preferred Facility
MontePrime EPO – Not covered
MonteCare PPO – $500 copay
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible
PHYSICIANS SERVICES (OFFICE VISITS INCLUDING MENTAL HEALTH/SUBSTANCE ABUSE CARE)
Montefiore Network
MontePrime EPO
Primary Care Physician – $0
Specialist – $0
Chiropractic Care (10 visits) – Not covered
Surgery - $0
MonteCare PPO
Primary Care Physician – $15 copay/visit
Specialist – $15 copay/visit
Chiropractic Care (10 visits) – $35 copay/visit
Surgery - $0
Empire BlueCard PPO Network
MontePrime EPO
Primary Care Physician – $35 copay/visit
Specialist – $50 copay/visit
Chiropractic Care (10 visits) – Not covered
Surgery - $50 copay/visit
MonteCare PPO
Primary Care Physician – 10%1 coinsurance after deductible
Specialist – 10%1 coinsurance after deductible
Chiropractic Care (10 visits) – 10%1 coinsurance after deductible
Surgery – 10%1 coinsurance after deductible
Out-of-network
MontePrime EPO
Primary Care Physician – Not covered
Specialist – Not covered
Chiropractic Care (10 visits) – Not covered
Surgery - Not covered
MonteCare PPO
Primary Care Physician – 30%2 coinsurance after deductible
Specialist – 30%2 coinsurance after deductible
Chiropractic Care (10 visits) – 30%2 coinsurance after deductible
Surgery – 30%2 coinsurance after deductible
OUTPATIENT SURGERY
Montefiore Network
MontePrime EPO – $0
MonteCare PPO – $0
Empire BlueCard PPO Network Preferred Facility
MontePrime EPO – Not covered
MonteCare PPO – $500 copay
Empire BlueCard PPO Network Non-preferred Facility
MontePrime EPO – Not covered
MonteCare PPO – $1,000 copay
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible
HOME HEALTH CARE – 200 VISITS
Montefiore Network
MontePrime EPO – $0
MonteCare PPO – $0
Empire BlueCard PPO Network
MontePrime EPO – $0
MonteCare PPO – $0
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – $0 after deductible
MATERNITY
Montefiore Network
MontePrime EPO – $0
MonteCare PPO – $0
Empire BlueCard PPO Network
MontePrime EPO – $0
MonteCare PPO – 10%1 coinsurance after deductible
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – 30%2 coinsurance after deductible
ALLERGY TEST AND TREATMENT
Montefiore Network
MontePrime EPO - $0
MonteCare PPO – $15 copay/visit; $0 for treatment
Empire BlueCard PPO Network
MontePrime EPO – $35/$50 copay/visit; $0 for treatment
MonteCare PPO – 10%1 coinsurance after deductible
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – 30%2 coinsurance after deductible
PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY
Montefiore Network
MontePrime EPO – $0
MonteCare PPO – $0
Empire BlueCard PPO Network
MontePrime EPO – Not covered
MonteCare PPO – 10%1 coinsurance after deductible
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO – 30%2 coinsurance after deductible
DURABLE MEDICAL EQUIPMENT
Montefiore Network
MontePrime EPO - 20%1 coinsurance
MonteCare PPO
Professional provider: 20%1 coinsurance
Facility: $0
Empire BlueCard PPO Network
MontePrime EPO - 20%1 coinsurance
MonteCare PPO
Professional provider: 20%1 coinsurance
Facility: 20%1 coinsurance after deductible
Out-of-network
MontePrime EPO – Not covered
MonteCare PPO
Professional provider: 20%1 coinsurance
Facility: 20%1 coinsurance after deductible
1 Percentage is applied to covered charges which are based on the rate paid to like-kind Empire in-network facilities if the facility is within the Empire area (i.e. the New York metropolitan area including NJ and CT) or the facility's actual charge if it is outside of the Empire area.
2 Reasonable and Customary charges are based on 150% of Medicare's National Provider Rate. The Plan benefit is then determined by applying the cost-sharing percentage (70%/80%) to this amount; you are responsible for paying the balance of the bill to the provider.