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:PPO Deductible:$1,000 Coinsurance:20% Max Out of Pocket:$5,000
Key Benefits Include:
Essential Health Benefits | Pharmacy
Z Metal Level
Gold Plan
Monthly Cost -- U Add

Summary

Overview

  • Preventive care, essential health benefits and services you’ll only get with Blue Plans
  • Network providers give you the lowest out-of-pocket costs
  • No deductibles for specialist and doctor office visits and no deductible for prescription drugs
  • Outpatient laboratory services covered at 100%
  • Blue Health SolutionsSM health and wellness resources
  • Coverage when you travel, both in the U.S. and around the globe, with BlueCard®
 

Coverage Additions

B iDental Individual and Family Plan
Includes Dental Coverage for the Entire Family
B iDental Pediatric Plan
Includes Only Pediatric Dental Coverage for Children
 

Other Insurance Options

Support Information

 
 
Health Care Reform: Things Are Changing
 
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) $1,000
  • In-Network Deductible (Rx) N/A
  • In-Network Medical Coinsurance 20%
  • In-Network Out-of-Pocket Maximum (Medical + Rx) $5,000
  • Out-of-Network Coinsurance Percentage 40%
  • Out-of-Network Deductible $2,000
  • Out-of-Network Out-of-Pocket Maximum $6,000
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Additional Coverage

  • Chiropractic Care 20% after deductible, 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 $20 Copay
  • Specialist Cost Share $40 Copay
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Emergency Services

  • Emergency Room Copay $150 Copay
%

Hospitalization

  • Home Health Care Services 20% after deductible, 60 visits per benefit period
  • Inpatient Hospital Services (Hospital Stay) 20% after deductible
  • Inpatient Physician & Surgical Services 20% after deductible
  • Skilled Nursing Facility 20% after deductible , 120 days per benefit period
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Laboratory Services

  • Imaging (CT/PET Scans & MRIs) 20% after deductible
  • Lab Outpatient & Professional Services No charge
  • X-rays & Diagnostic Imaging 20% after deductible
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Maternity & Newborn Care

  • Delivery and All Inpatient Services for Maternity Care 20% after deductible
  • Prenatal & Postnatal Care No charge
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Mental Health & Substance Use Disorder Services

  • Mental/Behavioral Health Outpatient Services 20% after deductible
  • Substance Abuse Disorder Inpatient Services 20% after deductible
  • Substance Abuse Disorder Outpatient Services 20% after deductible
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Pediatric Services, Oral & Vision Care

  • Eye Glasses for Children 50% Coinsurance
  • Routine Eye Exam $20 Copay
  • Routine Eye Exam for Children $20 Copay
Note: You will be required to purchase pediatric dental coverage as a standalone plan to meet the Essential Health Benefits requirement.
*

Prescription Drugs

  • Rx Tier 1 Generic $20 Retail/$40 Mail
  • Rx Tier 2 Preferred Brand Drugs $40 Retail/$100 Mail
  • Rx Tier 3 Non-Preferred Brand Drugs $60 Retail/$180 Mail
  • Rx Tier 4 Specialty High-Cost Drugs $60
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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 20% after deductible
  • Outpatient Rehabilitation Services 20% after deductible
  • Rehabilitative Occupational & Physical Therapy 20% after deductible, 30 visit maximum per benefit period combined
  • Rehabilitative Speech Therapy 20% after deductible, 30 visit maximum per benefit period