Employer groups may select from a choice of deductible options.
| Basic plan summary | Member pays |
|---|---|
| Deductible (per group anniversary benefit period) | $500/$1,000; $1,000/$2,000; $1,500/$3,000; individual/two-or-more persons |
| Coinsurance (member portion for most services) | 20% of allowed amounts after deductible has been met |
| Coinsurance maximum | $1,000/$2,000 individual/two or more persons |
| Maximum out-of-pocket (includes copays, deductible and coinsurance where applicable) | $5,000/$10,000 individual/two-or-more persons. After the maximum out-of-pocket 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 | $25 office visit copay |
| Telehealth visits | $25 office visit copay |
| Preventive care as defined by the Affordable Care Act | These services are paid at 100% of the allowable charge. Some of the services include:
|
| Drug coverage | |
| Prescription drugs and mail order | The quantity per prescription is a 30-day pharmacy supply or 90-day mail order supply. BlueRx Card $15/$50/$75; $150/20% up to $250 with mail order is 2½ x copay with ResultsRx formulary. Must use designated specialty pharmacy for all specialty prescriptions. |
| Medical services | |
| Emergency medical transportation | Subject to deductible/coinsurance |
| Inpatient surgery physician/surgical | |
| Inpatient facility fee | |
| Outpatient surgery physician/surgical | |
| Outpatient lab and radiology (includes advanced imaging) | Pays at 100% of allowable charges up to a combined maximum of $300 for each covered person, each benefit period |
| Emergency room | $250 copay then subject to deductible/coinsurance |
| Recovery/special needs | |
| Outpatient rehabilitation | Subject to deductible/coinsurance |
| Hospice | |
| Home social work visits | |
| Mental health | |
| Mental/behavioral health – inpatient services Requires pre-admission certification from New Directions Behavioral Health at (800) 952-5906 |
Subject to deductible/coinsurance |
| Mental/behavioral health – outpatient services | $25 office visit copay |
| Other | |
| Lifetime maximum | Unlimited |
| 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; 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.
Optional Benefits:
Additional program information
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 Comprehensive Major Medical 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
Contact us to learn more about the features of BlueEdge Comprehensive Major Medical.
