Outpatient 100 per cent 100 per cent 100 per cent 80 per cent after 80 per cent after alcohol and deductible deductible substance abuse care Vision care Eye exam 100 per cent 100 per cent 100 per cent 80 per cent $40 allowance after $20 co-pay after $15 co-pay 1 exam every 1 exam every 1 exam every 12 months 1 exam every 1 exam every 12 months 12 months 12 months 12 months Frames and $45 every $100 allowance, $130 allowance, 80 per cent up $45 for frames optical lenses 24 months for then savings of then 20 per cent to $100 per year $25/pair single frames and up to 35 per discount on vision lenses from cent at remaining select group participating balance for $40/pair bifocal centres frames, lenses $10 copay for $55/pair trifocal lenses lenses (amounts listed are allowances provided by insurance) Other benefits Physical and 100 per cent 100 per cent 100 per cent 80 per cent 80 per cent after other inpatient deductible 90 visits 60 visits therapy 60 visits Physical and 100 per cent 100 per cent 100 per cent 80 per cent after 80 per cent after other outpatient after $20 co-pay deductible deductible 90 visits therapy 60 visits 60 visits Durable medical 100 per cent 100 per cent 100 per cent 80 per cent Not covered equipment Annex III Empire Blue Cross PPO Plan outline
Outpatient alcohol and substance abuse care 100 per cent 100 per cent 100 per cent 80 per cent after deductible 80 per cent after deductible Vision care Eye exam 100 per cent 1 exam every 12 months 100 per cent after $20 co-pay 1 exam every 12 months 100 per cent after $15 co-pay 1 exam every 12 months 80 per cent 1 exam every 12 months $40 allowance 1 exam every 12 months Frames and optical lenses $45 every 24 months for frames and lenses from select group $100 allowance, then savings of up to 35 per cent at participating centres $130 allowance, then 20 per cent discount on remaining balance for frames, $10 copay for lenses 80 per cent up to $100 per year $45 for frames $25/pair single vision $40/pair bifocal lenses $55/pair trifocal lenses (amounts listed are allowances provided by insurance) Other benefits Physical and other inpatient therapy 100 per cent 90 visits 100 per cent 100 per cent 60 visits 80 per cent 80 per cent after deductible 60 visits Physical and other outpatient therapy 100 per cent 90 visits 100 per cent 100 per cent after $20 co-pay 60 visits 80 per cent after deductible 80 per cent after deductible 60 visits Durable medical equipment 100 per cent 100 per cent 100 per cent 80 per cent Not covered Annex III Empire Blue Cross PPO Plan outline
IC%202018%20-%2015%20-%20Renewal%20of%20the%20UNHQs-administered%20health%20ins.%20programme.docx