Everything is premium —
except the insurance premiums
Introducing
Empire Prism Deductible First EPO/PPO plans
SM
for large groups with 51+ eligible employees
You want choice. We have you covered with a range of deductible options.
oo A range of deductible options available on both EPO and PPO network
with $0 coinsurance on most in-network benefits.
oo Preventive always covered at 100% (not subject to deductible).
oo Upfront in-network deductible must be satisfied before standard Prism
in-network benefits/cost share applies (Preventive and Rx excluded).
oo After the deductible is met, the plan works like a traditional EPO/PPO
health plan covering a majority of the services at low or no copay.
oo Plan year and calendar year are available.
Your employees deserve
more. And now, they can
have it.
This year, your entire team can enjoy the innovative
benefits of health care coverage from Empire. For
more information on Empire’s Prism plan, call your
Broker or visit us online at empireblue.com. You’ll
be glad you did. And so will your employees.
Save even more with lower premiums
Comprehensive Prism EPO/PPO benefits but with lower premiums. Collecting the
deductible up front on a Prism plan can help reduce premiums as much as 5-10%.1
A comprehensive suite of health and wellness offerings
360° Health® is a comprehensive suite of preventive care programs, wellness information, case management and care coordination services,
all seamlessly integrated to help members achieve and maintain optimal health. 360° Health also helps lower employer costs and ultimately
produces higher levels of employee well-being and satisfaction. Note: The availability of specific programs depends upon the type of group
health plan.
Here’s and example of how the PrismSM Deductible First EPO plan works2
Member A:
$250 deductible option $25/$40
Prism plan
Medical care received
Cost of medical care
Member pays
Visit 1 — PCP Office Visit
Adult preventive physical
$120
$0
Visit 2 — PCP Office Visit
Diagnostic visit
$85
$85
Visit 3 — Lab
Blood work
$165
$165
Deductible satisfied —
you start paying a copay for medical care
Visit 4 — Specialty Visit
Orthopedic Visit
$210
$40 specialty copay
Visit 5 — Radiology
MRI
$700
$50 copay
Visit 6 — Hospital Admit
Inpatient Stay with Surgery
$15,000
$200 copay
$16,280
$540
Total
(1) These savings are only for medical (non-drug) claim cost. This is based on an average claims estimate for an average population. Savings may vary for your group. (2) These examples are for illustrative purposes only.
Actual benefit information and cost may vary. (3) Based on lists in New York Magazine’s June 2011 issue and searches of competitors’ websites provided by third party vendor NetMinder / The Ignition Group, 09/2011. (4)
U.S. News & World Report, America’s Best Hospitals (2011) health.usnews.com/best-hospitals/ranking and internal data, September 2011. (5) Administered by the Blue Cross and Blue Shield Association, January 2012
Blue Facts. Blue Cross Blue Shield Association website: www.bcbs.com/about/history. Network data includes the BlueCard program, extensive network of doctors, hospitals and other providers that participate in
independent Blue Cross and Blue Shield plans across the country.
29133NYEENEBS Rev. 6/12
Benefit snapshot options for PrismSM Deductible First EPO in-network plan
Copayment
(PCP/ Specialist)
Deductible
(Individual/ Family)*
Inpatient
Copayment
Emergency
Room
Ambulatory Surgery
Copayment
Ambulance
Copayment
$25 / $40 or
$35 / $50
$250 / $625
$100, $200, $500 per admit or $100
per day; up to 5 days per admit
$150, $200
or $250
$100, $200 or
Specialist Copay
$0, $50 or $150
$25 / $40 or
$35 / $50
$500 / $1,250
$100, $200, $500 per admit or $100
per day; up to 5 days per admit
$150, $200
or $250
$100, $200 or
Specialist Copay
$0, $50 or $150
$25 / $40 or
$35 / $50
$750 / $1,875
$100, $200, $500 per admit or $100
per day; up to 5 days per admit
$150, $200
or $250
$100, $200 or
Specialist Copay
$0, $50 or $150
$25 / $40 or
$35 / $50
$1,000 / $2,500
$100, $200, $500 per admit or $100
per day; up to 5 days per admit
$150, $200
or $250
$100, $200 or
Specialist Copay
$0, $50 or $150
$25 / $40 or
$35 / $50
$1,500 / $3,750
$100, $200, $500 per admit or $100
per day; up to 5 days per admit
$150, $200
or $250
$100, $200 or
Specialist Copay
$0, $50 or $150
$25 / $40 or
$35 / $50
$2,000 / $5,000
$100, $200, $500 per admit or $100
per day; up to 5 days per admit
$150, $200
or $250
$100, $200 or
Specialist Copay
$0, $50 or $150
*Family coverage is 2.5 times the individual coverage amount.
Are you looking for out-of-network benefits?
We are adding a cost-effective option to our portfolio — the PrismSM Deductible First PPO plan.
Benefit snapshot options for PrismSM Deductible First PPO plan
Out-of-Network Cost-Sharing Options***
(Member Responsibility)
Deductible**
Coinsurance
options
Coinsurance
Stop-Loss
Total Out-of-Network Out-of-Pocket
Maximum (Includes Out of Network
Deductible)
$25 / $40 or $35 / $50 $250 or $500
$1,000
20%
30%
$10,000
$3,000
$4,000
$25 / $40 or $35 / $50 $250 or $500
$1,000
20%
30%
$25,000
$6,000
$8,500
$25 / $40 or $35 / $50 $250, $500, $750 or $1,000
$2,000
20%
30%
$10,000
$4,000
$5,000
$25 / $40 or $35 / $50 $250, $500, $750 or $1,000
$2,000
20%
30%
$25,000
$7,000
$9,500
Copayment after
Deductible
(PCP/Specialist)
In Network Deductible*
(Member Responsibility)**
$25 / $40 or $35 / $50
$250, $500, $750, $1,000,
$1,500 or $2,000
$5,000
20%
30%
$10,000
$7,000
$8,000
$25 / $40 or $35 / $50
$250, $500, $750, $1,000,
$1,500 or $2,000
$5,000
20%
30%
$25,000
$10,000
$12,500
*Unless otherwise indicated, in-network deductible must be satisfied before member cost-share applies. In-network covered preventive
care covered at 100%. All other services subject to deductible. Out-of-network deductible selected must be $500 higher than the
in-network deductible. **Family coverage is 2.5 times the individual coverage amount. ***In-network and out-of-network deductibles
accumulate separately and do not apply toward each other.
With Empire’s Prism plan you can give your employees easy access to a quality network of doctors
and hospitals
oo Most of the best hospitals and doctors — as shown in New York Magazine™ “Best Doctors in New York”3 and most of the “best” hospitals4
listed in U.S. News & World Report.
oo Worldwide coverage: If your employees are traveling and need care, we’re there for them. BlueCard® Worldwide provides access to health
care coverage for members traveling in Europe, the Caribbean, Latin America, Asia, the South Pacific, Africa and the Middle East. As a member
of the BlueCard® network your employees have access to more than 90% of hospitals and more than 80% of doctors. That’s more than any
other insurer.5
360°Health®, a registered trademark, is administered by Health Management Corporation. Services provided by Empire HealthChoice Assurance, Inc., licensee of the Blue Cross and Blue Shield Association, an association
of independent Blue Cross and Blue Shield plans.