BlueChoice® Shared Pay Comprehensive
Employer groups may select from a choice of coinsurance options.
|Basic Plan Summary||Member Pays|
|Deductible (Per group anniversary benefit period)||$0|
|Shared Payment Amount||50% of allowed amounts|
|Coinsurance maximum||$750/$1,500; $1,500/$3,000; $3,000/$6,000 individual/two-or-more persons. No one family member may contribute more than the individual amount toward the family shared pay maximum. After the shared pay maximum has been met, benefits are paid at 100% of covered services for the remainder of the benefit period.|
|Maximum Out-of-Pocket (Includes copays, deductible and coinsurance where applicable)||$6,350/$12,700 individual/two-or-more persons.
After the shared payment maximum amount has been reached, eligible benefits will be paid at 100% of the allowed amount for the remainder of the benefit period.
|Doctor's Office Visits|
|Home and office visits (Includes eye exam)||Subject to shared payment then 100%|
|Preventive care as defined by the Affordable Care Act||These services are paid at 100% of the allowable charge.
Some of the services include:
|Prescription drugs||The quantity per prescription shall be the greater of a 34-day supply or 100 unit dosage, if defined as a maintenance drug.
BlueRx Card $15/$30/$45; Mail order is 2½ x copay
BlueRx Card $15/$50/$75; Mail order is 2½ x copay
BlueRx Card $100/$200 then 50% coinsurance; Mail order is subject to retail deductible/coinsurance
|Mail order drugs|
|Emergency medical transportation||Subject to shared payment then 100%|
|Inpatient surgery physician/surgical|
|Inpatient facility fee|
|Outpatient surgery physician/surgical|
|Outpatient lab and radiology|
|Advanced imaging (CT/PET scans, MRIs)|
|Emergency Room||$100 copay then subject to shared payment|
|Accidental Injury Services||Pays 100% up to $1,000 per person each benefit period then subject to shared payment
|Outpatient rehabilitation||Subject to shared payment then 100%|
|Home health care|
|Mental Illness/Substance Use Disorders|
|Mental illness/substance use disorders - inpatient services
Requires pre-admission certification from New Directions Behavioral Health at 1-800-952-5906
|Subject to shared payment then 100%|
|Mental illness/substance use disorders - outpatient services|
|Eligible dependents||Covered to age 26|
Exclusions: Following is a list of common non-covered services. For a complete list of limitations and exclusions, refer to your certificate.
Duplicate benefits provided under federal, state or local laws, regulations or programs except Medicaid; services involving cosmetic or reconstructive surgery (except as stated in the contract); charges for personal items; convalescent or custodial care or rest cure; routine adult eye exams (vision benefits are provided for insureds up to age 19); all keratotomy procedures; blood or payments to donors of blood; any service or supply related to the medical management of obesity, except services covered as preventive health benefits; services or supplies related to sex transformations; services related to the reversal of sterilization procedures; any medically-aided insemination procedure; charges for services by immediate relatives or by members of the household; acupuncture and admission for acupuncture; medically unnecessary services and admissions; services covered and payable under any medical expense payment provision of any automobile insurance policy; mental illness or substance use disorder services provided by a non-eligible provider; services, supplies or treatments not specifically listed as covered in the member’s contract.
Drug coverage limitation: Generic drugs are mandatory if available unless physician prescribes a brand drug.
Additional Program Information
- Inpatient Admissions - Pre-admission certification is required for all planned inpatient admissions.
- Benefit Period - The 12-month period based on the group anniversary month.
- Waiting Period - Businesses select a waiting period option.
Triple Option Plan
The Triple Option Plan is available to large groups 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.
Contact us to learn more about the features of Blue Choice Shared Pay Comprehensive.