Health Plan Details

 

In-Network

Out-of-Network

Plan Information

Description In-Network Out-of-Network
Annual Out-of-Pocket Maximum (includes deductibles, copays and coinsurance) Individual: $6,850 / Family: $13,700 Individual: $26,800 / Family: $26,800
Annual Deductible Individual: $6,700 / Family: $13,400 Individual: $13,400 / Family: $26,800
Coinsurance (%) 50% 50%
 

In-Network

Out-of-Network

Prescription Drug Coverage

Description In-Network Out-of-Network
Generic Drugs Preventive - $0
Condition Care Generic - $4 Copay
Low cost: $32 Copay
High cost: $32 Copay
Not Covered
Preferred Brand Drugs Condition Care Brand - $30 Copay
Low cost: 50% after Deductible
High cost: 50% after Deductible
Not Covered
Non-Preferred Brand Drugs
Low cost: 50% after Deductible
High cost: 50% after Deductible
Not Covered
Specialty Drugs
Low cost: 50% after Deductible
High cost: 50% after Deductible
Not Covered
List of Covered Drugs Medication Guide Not Covered
Three Month Mail Order Pharmacy Benefits Yes No
Prescription Drug Deductible In Network Health Deductible Not Covered
Prescription Drug Out of Pocket Maximum Not Applicable Not Applicable

Physician Office Services

Description In-Network Out-of-Network
Primary Care Physician $0 for first 3 visits,
$50 Copay for all other visits
50% after Deductible
Specialist $85 Copay 50% after Deductible

Preventive Services

Description In-Network Out-of-Network
Preventive Care (screening, immunizations, etc.) $0 50% (mammograms & colonoscopies are $0)

Vision

Description In-Network Out-of-Network
Routine Eye Exam for Children $0 (1 visit annual max) Not Covered
Routine Eye Exam for Adults Not Covered Not Covered

Child Dental Coverage

Description In-Network Out-of-Network
Routine Dental Care Not Covered Not Covered
Basic Dental Care Not Covered Not Covered
Major Dental Care Not Covered Not Covered
Medically Necessary Orthodontia Not Covered Not Covered

Adult Dental Coverage

Description In-Network Out-of-Network
Routine Dental Care Not Covered Not Covered
Basic Dental Care Not Covered Not Covered
Major Dental Care Not Covered Not Covered
Orthodontia Not Covered Not Covered
 

In-Network

Out-of-Network

Emergency and Urgent Care

Description In-Network Out-of-Network
Emergency Room Facility 50% after Deductible 50% after In-Network Deductible
Urgent Care Center $125 Copay 50% after Deductible

Hospital and Surgical Care

Description In-Network Out-of-Network
Ambulatory Surgical Center $100 Copay after Deductible 50% after Deductible
Outpatient Hospital Facility $125 Copay after Deductible 50% after Deductible
Inpatient Hospital Facility $150 Copay after Deductible 50% after Deductible
Physicians Services (all locations) Deductible In-Network Deductible

Outpatient Diagnostic Services

Description In-Network Out-of-Network
Laboratory Services $0 Not Covered
Basic Imaging (e.g. x-ray, ultrasound) 50% after Deductible 50% after Deductible
Advanced Imaging (e.g. CT/CAT Scan, MRI, MRA) 50% after Deductible 50% after Deductible

Other Benefits

Description In-Network Out-of-Network
Mental/Behavioral Health Outpatient Facility Services $125 Copay after Deductible 50% after Deductible
Mental/Behavioral Health Inpatient Facility Services $150 Copay after Deductible 50% after Deductible
Substance Abuse Dependency Outpatient Facility Services $125 Copay after Deductible 50% after Deductible
Substance Abuse Dependency Inpatient Facility Services $150 Copay after Deductible 50% after Deductible
Outpatient Rehabilitation Facility 50% after Deductible (35 visit annual max) 50% after Deductible (35 visit annual max)
Habilitative Services 50% after Deductible (35 visit annual max) 50% after Deductible (35 visit annual max)
Skilled Nursing Facility 50% after Deductible 50% after Deductible
Prenatal and Postnatal - Office Visit $85 Copay 50% after Deductible
Labor and Delivery - Hospital Stay $150 Copay after Deductible 50% after Deductible
BlueSelect Everyday Health 1449

Plan Information

Annual Out-of-Pocket Maximum (includes deductibles, copays and coinsurance)
Individual: $6,850 / Family: $13,700
Annual Deductible
Individual: $6,700 / Family: $13,400
Coinsurance (%)
50%

Prescription Drugs

Generic Drugs
Preventive - $0
Condition Care Generic - $4 Copay
Low cost: $32 Copay
High cost: $32 Copay
Preferred Brand Drugs
Condition Care Brand - $30 Copay
Low cost: 50% after Deductible
High cost: 50% after Deductible
Non-Preferred Brand Drugs

Low cost: 50% after Deductible
High cost: 50% after Deductible
Specialty Drugs

Low cost: 50% after Deductible
High cost: 50% after Deductible
List of Covered Drugs
Three Month Mail Order Pharmacy Benefits
Yes
Prescription Drug Deductible
In Network Health Deductible
Prescription Drug Out of Pocket Maximum
Not Applicable

Physician Office Services

Primary Care Physician
$0 for first 3 visits,
$50 Copay for all other visits
Specialist
$85 Copay

Preventive Services

Preventive Care (screening, immunizations, etc.)
$0

Vision

Routine Eye Exam for Children
$0 (1 visit annual max)
Routine Eye Exam for Adults
Not Covered

Child Dental Coverage

Routine Dental Care
Not Covered
Basic Dental Care
Not Covered
Major Dental Care
Not Covered
Medically Necessary Orthodontia
Not Covered

Adult Dental Coverage

Routine Dental Care
Not Covered
Basic Dental Care
Not Covered
Major Dental Care
Not Covered
Orthodontia
Not Covered

Emergency and Urgent Care

Emergency Room Facility
50% after Deductible
Urgent Care Center
$125 Copay

Hospital and Surgical Care

Ambulatory Surgical Center
$100 Copay after Deductible
Outpatient Hospital Facility
$125 Copay after Deductible
Inpatient Hospital Facility
$150 Copay after Deductible
Physicians Services (all locations)
Deductible

Other Benefits

Mental/Behavioral Health Outpatient Facility Services
$125 Copay after Deductible
Mental/Behavioral Health Inpatient Facility Services
$150 Copay after Deductible
Substance Abuse Dependency Outpatient Facility Services
$125 Copay after Deductible
Substance Abuse Dependency Inpatient Facility Services
$150 Copay after Deductible
Outpatient Rehabilitation Facility
50% after Deductible (35 visit annual max)
Habilitative Services
50% after Deductible (35 visit annual max)
Skilled Nursing Facility
50% after Deductible
Prenatal and Postnatal - Office Visit
$85 Copay
Labor and Delivery - Hospital Stay
$150 Copay after Deductible

Plan Information

Annual Out-of-Pocket Maximum (includes deductibles, copays and coinsurance)
Individual: $26,800 / Family: $26,800
Annual Deductible
Individual: $13,400 / Family: $26,800
Coinsurance (%)
50%

Prescription Drugs

Generic Drugs
Not Covered
Preferred Brand Drugs
Not Covered
Non-Preferred Brand Drugs
Not Covered
Specialty Drugs
Not Covered
List of Covered Drugs
Not Covered
Three Month Mail Order Pharmacy Benefits
No
Prescription Drug Deductible
Not Covered
Prescription Drug Out of Pocket Maximum
Not Applicable

Physician Office Services

Primary Care Physician
50% after Deductible
Specialist
50% after Deductible

Preventive Services

Preventive Care (screening, immunizations, etc.)
50% (mammograms & colonoscopies are $0)

Vision

Routine Eye Exam for Children
Not Covered
Routine Eye Exam for Adults
Not Covered

Child Dental Coverage

Routine Dental Care
Not Covered
Major Dental Care
Not Covered
Medically Necessary Orthodontia
Not Covered
Basic Dental Care
Not Covered

Adult Dental Coverage

Routine Dental Care
Not Covered
Major Dental Care
Not Covered
Orthodontia
Not Covered

Emergency and Urgent Care

Emergency Room Facility
50% after In-Network Deductible
Urgent Care Center
50% after Deductible

Hospital and Surgical Care

Ambulatory Surgical Center
50% after Deductible
Outpatient Hospital Facility
50% after Deductible
Inpatient Hospital Facility
50% after Deductible
Physicians Services (all locations)
In-Network Deductible

Outpatient Diagnostic Services

Laboratory Services
$0
Basic Imaging (e.g. x-ray, ultrasound)
50% after Deductible
Advanced Imaging (e.g. CT/CAT Scan, MRI, MRA)
50% after Deductible

Outpatient Diagnostic Services

Laboratory Services
Not Covered
Basic Imaging (e.g. x-ray, ultrasound)
50% after Deductible
Advanced Imaging (e.g. CT/CAT Scan, MRI, MRA)
50% after Deductible

Other Benefits

Mental/Behavioral Health Outpatient Facility Services
50% after Deductible
Mental/Behavioral Health Inpatient Facility Services
50% after Deductible
Substance Abuse Dependency Outpatient Facility Services
50% after Deductible
Substance Abuse Dependency Inpatient Facility Services
50% after Deductible
Outpatient Rehabilitation Facility
50% after Deductible (35 visit annual max)
Habilitative Services
50% after Deductible (35 visit annual max)
Skilled Nursing Facility
50% after Deductible
Prenatal and Postnatal - Office Visit
50% after Deductible
Labor and Delivery - Hospital Stay
50% after Deductible

Please note these are estimated costs based on the responses you’ve provided. Actual costs are based on the answers provided on the application.

These policies have limitations and exclusions. The amount of benefits and premium provided may vary based on the plan selected.

BCRQ.IU.BB 0515 - BlueCare for Individuals Non-Group Contract
BOPQ.IU.BB 0413 - BlueOptions for Individuals Non-Group Contract
BSEQ.IU.BB 0413 - BlueSelect for Individuals Non-Group Contract

CWS SHP 004 NF 102015