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Network:PPO Deductible:$250 Coinsurance:10% Max Out of Pocket:$1,400
Key Benefits Include:
Essential Health Benefits | Pharmacy
! Metal Level
Platinum Plan
Monthly Cost -- U Add

Summary

Overview

  • All the essential health benefits, preventive care and more
  • The lowest out-of-pocket costs with network providers
  • No deductible for prescription drugs
  • A low out-of-pocket maximum
  • Valuable Blue Plan extras, such as Blue Health SolutionsSM health and wellness resources
  • Coverage almost anywhere in the world 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) $250
  • In-Network Deductible (Rx) N/A
  • In-Network Medical Coinsurance 10%
  • In-Network Out-of-Pocket Maximum (Medical + Rx) $1,400
  • 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 10% 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
#

Ambulatory Patient Services

  • PCP Cost Share 10% after deductible
  • Specialist Cost Share 10% after deductible
$

Emergency Services

  • Emergency Room Copay 10% after deductible
%

Hospitalization

  • Home Health Care Services 10% after deductible, 60 visits per benefit period
  • Inpatient Hospital Services (Hospital Stay) 10% after deductible
  • Inpatient Physician & Surgical Services 10% after deductible
  • Skilled Nursing Facility 10% after deductible, 120 days per benefit period
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Laboratory Services

  • Imaging (CT/PET Scans & MRIs) 10% after deductible
  • Lab Outpatient & Professional Services 10% after deductible
  • X-rays & Diagnostic Imaging 10% after deductible
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Maternity & Newborn Care

  • Delivery and All Inpatient Services for Maternity Care 10% after deductible
  • Prenatal & Postnatal Care No charge
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Mental Health & Substance Use Disorder Services

  • Mental/Behavioral Health Outpatient Services 10% after deductible
  • Substance Abuse Disorder Inpatient Services 10% after deductible
  • Substance Abuse Disorder Outpatient Services 10% after deductible
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Pediatric Services, Oral & Vision Care

  • Eye Glasses for Children 50% Coinsurance
  • Routine Eye Exam 10% after deductible
  • Routine Eye Exam for Children 10% after deductible
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 $10 Retail/$20 Mail
  • Rx Tier 2 Preferred Brand Drugs $25 Retail/$62.50 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 10% after deductible
  • Outpatient Rehabilitation Services 10% after deductible
  • Rehabilitative Occupational & Physical Therapy 10% after deductible, 30 visit maximum per benefit period combined
  • Rehabilitative Speech Therapy 10% after deductible, 30 visit maximum per benefit period