2025 NYSHIP Plan Comparison
Disclaimer: Please visit your HMO's website for the most up-to-date benefit information and any mid-year prescription drug formulary changes.
| Highmark Blue Cross Blue Shield (View SBC) (View Drug Formulary) | |
|---|---|
| Office Visits | $10 per visit [1] |
| Annual Adult Routine Physicals | No copayment |
| Well Child Care | No copayment |
| Specialty Office Visits | $15 per visit [1] |
| Diagnostic/Therapeutic Services | |
| Radiology | $15 per visit |
| Lab Tests | No copayment [2] |
| Pathology | No copayment |
| EKG/EEG | $15 per visit |
| Radiation | $15 per visit |
| Chemotherapy | $15 per visit |
| Dialysis | $10 per visit |
| Women's Health Care/Reproductive Health | |
| Pap Tests | No copayment |
| Mammograms | No copayment |
| Prenatal Visits | $10 per visit [3] |
| Postnatal Visits | $10 per visit |
| Bone Density Tests | No copayment |
| Breastfeeding Services and Equipment | No copayment [4] |
| External Mastectomy Prosthesis | No copayment, one per breast per year |
| Family Planning Services | $15 per visit |
| Infertility Services | $15 per visit |
| Contraceptive Drugs | No copayment [5] |
| Contraceptive Devices | No copayment [5] |
| Inpatient Hospital Surgery | No copayment |
| Physician | |
| Facility | |
| Outpatient Surgery | |
| Hospital | $100 per visit |
| Physician's Office | $15 per visit |
| Outpatient Surgery Facility | $100 per visit |
| Weight Loss/Bariatric Surgery | $100 copayment |
| Emergency Department | $100 per visit (waived if admitted) |
| Urgent Care Facility | No copayment [6] |
| Ambulance | $100 per trip |
| Telehealth | Virtual Care PCP/Specialist: $10/$15 per visit with an in-network provider |
| Virtual Portal | Well360 Virtual Health: No copayment |
| Outpatient Mental Health | |
| Individual | $10 per visit, unlimited |
| Group | $10 per visit, unlimited |
| Inpatient Mental Health | No copayment, unlimited |
| Outpatient Drug/Alcohol Rehab | $10 per visit, unlimited |
| Inpatient Drug/Alcohol Rehab | No copayment, unlimited |
| Durable Medical Equipment | 50% coinsurance |
| Prosthetics | 20% coinsurance |
| Orthotics | 20% coinsurance |
| Rehabilitative Care, Physical, Speech and Occupational Therapy | |
| Inpatient | No copayment, unlimited [7] |
| Outpatient Physical or Occupational Therapy | $15 per visit, 20 visits max [8] |
| Outpatient Speech Therapy | $15 per visit, 20 visits max [8] |
| Diabetic Supplies | $10 per item |
| Retail | |
| Mail Order | |
| Insulin and Oral Agents | No copayment |
| Retail | |
| Mail Order | |
| Diabetic Shoes | Not covered |
| Hospice | No copayment |
| Skilled Nursing Facility | No copayment, 100 days max per plan year |
| Prescription Drugs | |
| Retail | $5 Tier 1, $30 Tier 2, $60 Tier 3, 30-day supply |
| Mail Order | $10 Tier 1, $60 Tier 2, $120 Tier 3, 90-day supply |
| Additional Prescription Drug Related Information | May require prior approval. Over 600 $0 preventive drugs available. |
| Specialty Drugs | Available through mail order at the applicable copayment. |
| Additional Benefits | |
| Annual Out-of-Pocket Maximum (In-Network Benefits) | $3,000 Individual, $6,000 Family per year |
| Dental | Not covered |
| Vision | Eye exams covered in full. Eyewear discounts available. [9] |
| Hearing Aids | 50% coinsurance when obtained from a participating provider. Discounts available through Blue365. [10] |
| Out of Area | Worldwide coverage for emergency care through the BlueCard Program. Away From Home Care (AFHC) allows you to obtain coverage through a nearby Blue HMO when you are away from home and our service area. Call the number on the back of your ID card for more information. |
| Additional Benefits HMOs (as applicable) | |
| In Vitro Fertilization | $15 copayment, Three treatment rounds of IVF per lifetime max, other artificial means to induce pregnancy (embryo transfer, etc.) are not covered. |
| Wellness Services | $600 Single/$750 Family wellness card annual allowance for use at participating vendors. Funds do not roll over. |
| Plan Highlights for 2025 | $0 specialist office visits for children under age 19. $0 urgent care. A 90-day supply of prescription drugs for two copayments. New weight management and perioperative programs. |
| Participating Physicians | You have access to 11,000+ physicians and healthcare professionals. |
| Affiliated Hospitals | You may receive care at all Western New York hospitals and other hospitals if medically necessary. |
| Pharmacies and Prescriptions | Our network includes 45,000 participating pharmacies. Prescriptions filled up to 31-day supply. |
| Medicare Coverage | Medicare-primary enrollees are required to enroll in Senior Blue HMO, our Medicare Advantage Plan. To qualify, you must enroll in Medicare Parts A & B and live in the service area. |
Footnotes
Highmark Blue Cross Blue Shield
[1]
No copayment for primary and specialty care visits for children age 19 and under.
[2]
Members are required to use Quest Diagnostics or an outpatient hospital that participates as a Quest Diagnostics hospital draw site.
[3]
$10 copayment for the final visit only.
[4]
For hospital-grade pump rental, covered for duration of breastfeeding. $170 allowance towards purchase of one manual/electric pump per pregnancy.
[5]
No copayment for contraceptive drugs and devices unless a generic equivalent is available, in which case you are subject to a $30 (Tier 2) or $60 (Tier 3) copayment.
[6]
Urgent care is covered worldwide.
[7]
Prior authorization is required.
[8]
Twenty visits in aggregate for physical therapy, occupational therapy and speech therapy.
[9]
Through Davis Vision providers only.
[10]
For more information, visit www.blue365deals.com/WNY