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 | $1,000 / $2,000 |
| Deductible family | $3,000 / $6,000 |
| Coinsurance (choose from 20% or 50%) |
20% (with either deductible level) or 50% (with $1,000 ind./$3,000 family deductible only) |
| Individual out-of-pocket maximum after deductible | $1,000 (with 20% coinsurance option) or $5,000 (with 50% coinsurance option) |
| Family out-of-pocket maximum after deductible | $3,000 (with 20% coinsurance option) or $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 or 15 per family); then 20% / 50% coinsurance after deductible |
| Office visit - specialist | $25 copay (first five visits of any office visit type or 15 per family); 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 | $50 initial accident 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. There are also several preventive services for women paid at 100% of the allowable charge for new enrollees on or after Aug. 1, 2012. For a complete listing, please click here. | |
| 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 or 15 per family); then 20% / 50% coinsurance after deductible (spouses must be enrolled in same plan) |
| Labor and delivery hospital stay | 20% / 50% coinsurance after deductible (spouses must be enrolled in same plan) |
| Additional coverage | |
| Mental health | $25 copay (first five visits of any office visit type or 15 per family); then 20% / 50% coinsurance after deductible |
| Substance abuse | $25 copay (first five visits of any office visit type or 15 per family); then 20% / 50% coinsurance after deductible |
| Optional benefits | |
| Dental program | Dental coverage options |
| Hospital Indemnity Plan (HIP) | Cash benefits during hospitalization |
| Life insurance | Protection up to $50,000 |
| LTC Blue | Long-term care insurance |
| Plan 150 | Cancer policy |
Exclusions
See the Exclusions page for details.
Additional Program Information
More Information
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