Open Enrollment Ended March 31st. If you have a qualifying life event, you may still be able to buy coverage for 2014. Call us today at 1.866.514.2454. Learn more.
Network:Custom PPO Deductible:$1,500 Coinsurance:25% Max Out of Pocket:$6,350
Key Benefits Include:
Essential Health Benefits | Pharmacy
Y Metal Level
Silver Plan
Monthly Cost -- U Add

Summary

Overview

  • Coverage for the essential health benefits and preventive care
  • Pay the lowest out-of-pocket costs when you use network doctors and facilities
  • No deductibles for specialist and doctor office visits and no deductible for prescription drugs
  • No coinsurance and no deductible for high-tech imaging, labs and x-rays
  • Blue Plan extras, like health & wellness resources with Blue Health SolutionsSM and coverage when you travel with BlueCard®
  • Cost-sharing reductions available

Pharmacy Information


Other Insurance Options

Support Information



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How Can I Get Health Insurance for My Family?

Health Plan Benefits

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General Benefits

  • HSA Qualified No
  • In-Network Deductible (Medical) $1,500
  • In-Network Deductible (Rx) N/A
  • In-Network Medical Coinsurance 25%
  • In-Network Out-of-Pocket Maximum (Medical + Rx) $6,350
  • Out-of-Network Coinsurance Percentage 50%
  • Out-of-Network Deductible $6,000
  • Out-of-Network Out-of-Pocket Maximum $10,000
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Additional Coverage

  • Chiropractic Care $60 Copay, 20 visit maximum per benefit period limited to age 13 and up
  • Durable Medical Equipment 50% after deductible
  • Prosthetic Devices 50% after deductible
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Ambulatory Patient Services

  • PCP Cost Share $40 Copay
  • Specialist Cost Share $60 Copay
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Emergency Services

  • Emergency Room Copay $200 Copay
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Hospitalization

  • Home Health Care Services 25% after deductible
  • Inpatient Hospital Services (Hospital Stay) $250 copay (First day), 25% after deductible
  • Inpatient Physician & Surgical Services 25% after deductible
  • Skilled Nursing Facility $250 copay (First day), 25% after deductible, 120 days per benefit period
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Laboratory Services

  • Imaging (CT/PET Scans & MRIs) $150 Copay
  • Lab Outpatient & Professional Services $40 Copay
  • X-rays & Diagnostic Imaging $40 Copay
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Maternity & Newborn Care

  • Delivery and All Inpatient Services for Maternity Care $250 copay (First day), 25% after deductible
  • Prenatal & Postnatal Care No charge
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Mental Health & Substance Use Disorder Services

  • Mental/Behavioral Health Outpatient Services 25% after deductible
  • Substance Abuse Disorder Inpatient Services $250 copay (First day), 25% after deductible
  • Substance Abuse Disorder Outpatient Services 25% after deductible
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Pediatric Services, Oral & Vision Care

  • Eye Glasses for Children 50% Coinsurance
  • Routine Eye Exam $40 Copay
  • Routine Eye Exam for Children $40 Copay
Note: You will be required to purchase pediatric dental coverage as a standalone plan to meet the Essential Health Benefits requirement.
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Prescription Drugs

  • Rx Tier 1 Generic $25 Retail/$50 Mail
  • Rx Tier 2 Preferred Brand Drugs $50 Retail/$125 Mail
  • Rx Tier 3 Non-Preferred Brand Drugs $75 Retail/$225 Mail
  • Rx Tier 4 Specialty High-Cost Drugs $75
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Preventive / Wellness Services & Chronic Disease Management

  • Preventive Care/Screening/Immunization No charge
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Rehabilitative & Habilitative Services and Devices

  • Habilitation Services $60 Copay
  • Outpatient Rehabilitation Services $60 Copay
  • Rehabilitative Occupational & Physical Therapy $60 Copay, 30 visit maximum per benefit period combined
  • Rehabilitative Speech Therapy $60 Copay, 30 visit maximum per benefit period