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Group Health Plans | More than 50 Employees

Blue Choice Comprehensive Major Medical (40% coinsurance)

Employer groups may select from a choice of deductible options.

Basic Plan Summary Member Pays
Deductible (Per group anniversary benefit period) $1,500/$3,000 individual/two-or-more persons
Coinsurance (Member portion for most services) 40% of allowed amounts after deductible has been met
Coinsurance maximum $2,000/$4000 individual/two-or-more persons
Maximum Out-of-Pocket (Includes copays, deductible and coinsurance where applicable) $6,350/$12,700 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 $30 office visit copay on first 5 visits, then subject to deductible/coinsurance*
Telehealth visits $30 office visit copay on first 5 visits, then subject to deductible/coinsurance*
Home and office visits - Specialist $60 office visit copay on first 5 visits, then subject to deductible/coinsurance*

* Combined limit of Primary, Specialist and Telehealth office visits.
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 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.

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)
Emergency Room $300 copay then subject to deductible/coinsurance; waived if patient is admitted within 24 hours to any hospital for any condition
Accidental Injury Services Pays 100% up to $1,000 per person each benefit period, then subject to deductible/coinsurance
Recovery/Special Needs
Outpatient rehabilitation Subject to deductible/coinsurance
Home social work visits
Short-term Therapies - Physical, Speech and Occupational, Respiratory and Cardiac Subject to office visit copay based on specialty. (Visits count towards the 5 office visit limit per benefit period. Office visits are subject to deductible/coinsurance starting with the 6th visit) and subject to Outpatient Short Term Therapy visitation limits (regardless of place of service):
Outpatient Speech Therapy: 30 visits
Outpatient Rehab: 40 visits
Spinal Manipulations: 20 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 $30 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 Blue Choice Comprehensive Major Medical.