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Group Health Plans | More than 50 Employees

BlueEdge Comprehensive Major Medical Program

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
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 $35 office visit copay
Telemedicine visits $35 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:
  • Routine screenings
  • Preventive immunizations
  • Well-woman visits/screenings
  • Contraceptive methods
Drug Coverage
Prescription drugs & mail order The quantity per prescription is a 30-day pharmacy supply
or 90-day mail order supply.

BlueRX Card $15 generic/$100/$200 deductible then preferred brand-40% coinsurance (member pays) with a minimum of $30 or whichever is greater AND non preferred brand-60% coinsurance with a minimum of $50 or whichever is greater with mail order 2½ x copay ($37.50) for Generic, preferred brand-40% coinsurance with a minimum of $75 or whichever is greater and non-preferred brand-60% coinsurance with a minimum of $125 or whichever is greater with ResultsRx formulary. Mail Order subject to retail deductible and coinsurance.

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
Home social work visits
Mental Health
Mental/behavioral health - inpatient services
Requires pre-admission certification from New Directions Behavioral Health at 1-800-952-5906
Subject to deductible/coinsurance
Mental/behavioral health - outpatient services $35 office visit copay
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

  • 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 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.