| Plan options: |
Blue Advantage HMO
(in-network benefits only)
|
Blue Choice Narrow Network PPO |
Blue Choice Options
High Deductible PPO
Plan A
|
Blue Choice Options
High Deductible PPO
Plan B
|
Blue Choice Options
PPO
|
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| Network | Blue Advantage HMO [ADV] | Blue Choice Select PPO [BCS] |
Blue Choice Options
(Tier 1)
|
PPO
(Tier 2)
|
Out-of-Network (Tier 3) |
Blue Choice Options (Tier 1) |
PPO (Tier 2) |
Out-of-Network (Tier 3) |
Blue Choice Options
(Tier 1)
|
PPO
(Tier 2)
|
Out-of-Network (Tier 3) |
|
Deductible
Individual (In-Network / Out-of-Network) Family (In-Network / Out-of-Network) |
$1,000
$2,000
|
$1,000 / $3,000
$3,000 / $9,000 |
$3,400
$6,800 |
$4,000
$8,000 |
$5,000
$10,000 |
$4,200
$8,400 |
$4,800
$8,600 |
$8,000
$16,000 |
$1,000
$3,000 |
$2,000
$6,000 |
$3,000
$9,000 |
| Coinsurance In-Network / Out-of-Network |
90% | 80% / 50% | 90% | 85% | 70% | 85% | 80% | 60% | 80% | 60% | 50% |
|
Out-of-Pocket Max
Individual (In-Network / Out-of-Network) Family (In-Network / Out-of-Network) |
$2,000
$4,000
Max in Copays |
$2,000 / $9,000
$6,000 / $27,000 Includes Deductible |
$4,000
$8,000 |
$5,000
$10,000 |
$10,000
$20,000 |
$6,350
$12,700 |
$6,800
$10,000 |
$16,000
$32,000 |
$2,000
$6,000 |
$3,000
$9,000 |
$9,000
$27,000 |
| Physician Services (In- Network) Well Adult/Child Physician Office / Specialist Visit X-Rays / Lab Diagnostics Telemedicine |
100% $20 / $40 copay 100% N/A |
100% $20 copay Deductible then 50% $20 / $40 copay |
100% Deductible then 90% Deductible then 90% Deductible then 90% $48 Copay |
100% Deductible then 85% Deductible then 85% Deductible then 85% $48 Copay |
Deductible then 70% Deductible then 70% Deductible then 70% Deductible then 70% $48 Copay |
100% Deductible then 85% Deductible then 85% Deductible then 85% $48 Copay |
100% Deductible then 80% Deductible then 80% Deductible then 80% $48 Copay |
Deductible then 60% Deductible then 60% Deductible then 60% Deductible then 60% $48 Copay |
100% $20 copay $40 copay Deductible then 80% OV/SP Copay |
100% $30 copay $50 copay Deductible then 60% OV/SP Copay |
Deductible then 50% Deductible then 50% Deductible then 50% Deductible then 50% OV/SP Copay |
| Emergency Room | $250 copay | $250 copay | Deductible then 90% | Deductible then 85% | Deductible then 70% | Deductible then 85% | Deductible then 80% | Deductible then 60% | $250 copay | ||
| Urgent Care (In-Network) |
$20 copay | Deductible then 80% | Deductible then 90% | Deductible then 85% | Deductible then 70% | Deductible then 85% | Deductible then 80% | Deductible then 60% | Deductible then 80% | Deductible then 50% | |
|
Prescription Drugs (In-
Network) Retail Generic / Preferred Brand / Non- Preferred Brand / Specialty 34 Day Supply Prescription Out-of-Pocket Max Individual / Family |
Copays:
$10 / $40 / $60 / $60 $2,500 / $5,000 |
Copays:
$10 / $40 / $60 / $60 $2,500 / $7,500 |
Deductible then 90% | Deductible then 70% | Deductible then 90% | Deductible then 70% |
Copays:
$10 / $40 / $60 / $60 $2,500 / $7,500
|
In network copay + 25%
$2,500 / $7,500
|
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