Affordable coverage with protection from larger expenses.
| Basic plan summary | |
|---|---|
| Plan type | PPO (Preferred Provider Organization) – Allows you to choose to receive care from network providers of your choice. |
| Deductible individual | $500 / $1,000 / $2,000 |
| Deductible family | $1,500 / $3,000 / $6,000 |
| Coinsurance (choose from 20% or 50%) |
20% / 50% (with $1,000/$3,000 deductible) |
| Individual out-of-pocket maximum after deductible | $1,000 / $5,000 (with 50% coinsurance option) |
| Family out-of-pocket maximum after deductible | $3,000 / $15,000 (with 50% coinsurance option) |
| Individual lifetime maximum | Unlimited |
| Dependent coverage | Eligible children covered to age 26 |
| HSA eligibility | No |
| Doctor office visits (illness and injury) | |
| Office visit - history and exam | $25 copay (first five visits of any office visit type); then 20% / 50% coinsurance after deductible |
| Office visit - specialist | $25 copay (first five visits of any office visit type); then 20% / 50% coinsurance after deductible |
| How can I find a doctor in this plan's Network? | Search for a doctor or hospital here |
| Do I need permission from my primary care doctor to see a specialist? | No |
| Do I need authorization before seeing an out-of-network doctor? | No |
| Hospital services | Your cost sharing |
| Emergency room | 20% / 50% coinsurance after deductible |
| Accident coverage | $50 copay; then 20% / 50% coinsurance after deductible |
| Outpatient Lab/X-ray | No charge for first $300/$900; then 20% / 50% coinsurance after deductible |
| Outpatient surgery | 20% / 50% coinsurance after deductible |
| Hospitalization | 20% / 50% coinsurance after deductible |
| Preventive care | |
| As part of the Affordable Care Act, preventive services are paid at 100% of the allowable charge for new enrollees after Sept. 23, 2010. This includes routine screenings, immunizations, checkups and counseling received to prevent illness or disease. Learn more. | |
| Periodic health exam | No charge |
| Periodic OB-GYN exam | No charge |
| Well baby care | No charge |
| Prescription drug | |
| Generic | 50% coinsurance after $100 ind./ $300 family deductible with BlueRx rider |
| Brand | 50% coinsurance after $100 ind./$300 family deductible with BlueRx rider |
| Non-formulary | 50% coinsurance after $100 ind./$300 family deductible with BlueRx rider |
| Prescription drug – Mail order | |
| Generic | Not covered |
| Brand | Not covered |
| Non-formulary | Not covered |
| Maternity coverage | |
| Pre and postnatal office visit | $25 copay (first five visits of any office visit type); then 20% / 50% coinsurance after deductible |
| Labor and delivery hospital stay | 20% coinsurance after deductible |
| Additional coverage | |
| Mental health | $25 copay (first five visits of any office visit type); then 20% / 50% coinsurance after deductible |
| Substance abuse | $25 copay (first five visits of any office visit type); then 20% / 50% coinsurance after deductible |
| Optional benefits | |
| Dental program | Dental coverage options |
| Hospital Indemnity Plan (HIP) | Cash benefits during hospitalization |
| Life insurance | Life coverage options |
| LTC Blue | Long-term care insurance |
| Plan 150 | Cancer policy |
Exclusions
Exclusions page for details.
Additional Program Information
Triple Option Plan
The Triple Option Plan is available to groups of 2 to 50 employees with this product. The plan offers employees one of three out-of-pocket choices annually within the Shared Pay Comprehensive benefit program. The employer must contribute at least 25 percent of the employee-only premium amount for the highest out-of-pocket option. This stabilizes the group's base and gives the employees the option to "buy up" to a better level of coverage, based on their personal insurance needs.
More Information