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: $12,500 / Family: $25,000
Annual Deductible Individual: $6,100 / Family: $12,200 Individual: $12,200 / Family: $24,400
Coinsurance (%) 30% 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: $30 Copay after Deductible
High cost: $30 Copay after Deductible
Not Covered
Preferred Brand Drugs Condition Care Brand - $23 Copay
Low cost: $45 Copay after Deductible
High cost: $45 Copay after Deductible
Not Covered
Non-Preferred Brand Drugs Low cost: $160 Copay after Deductible
High cost: $160 Copay after Deductible
Not Covered
Specialty Drugs Low cost: $200 Copay after Deductible
High cost: $200 Copay 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 visit,
$65 Copay for all other visits
50% after Deductible
Specialist $90 Copay after Deductible 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 $0 Not Covered
Basic Dental Care $0 Not Covered
Major Dental Care $0 Not Covered
Medically Necessary Orthodontia $0 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 $600 Copay after Deductible $600 Copay after In-Network Deductible
Urgent Care Center $250 Copay after Deductible 50% after Deductible

Hospital and Surgical Care

Description In-Network Out-of-Network
Ambulatory Surgical Center 30% after Deductible 50% after Deductible
Outpatient Hospital Facility 30% after Deductible 50% after Deductible
Inpatient Hospital Facility 30% after Deductible 50% after Deductible
Physicians Services (all locations) $0 $0

Outpatient Diagnostic Services

Description In-Network Out-of-Network
Laboratory Services $0 50% after Deductible
Basic Imaging (e.g. x-ray, ultrasound) $4 Copay 50% after Deductible
Advanced Imaging (e.g. CT/CAT Scan, MRI, MRA) 30% after Deductible 50% after Deductible

Other Benefits

Description In-Network Out-of-Network
Mental/Behavioral Health Outpatient Facility Services 30% after Deductible 50% after Deductible
Mental/Behavioral Health Inpatient Facility Services 30% after Deductible 50% after Deductible
Substance Abuse Dependency Outpatient Facility Services 30% after Deductible 50% after Deductible
Substance Abuse Dependency Inpatient Facility Services 30% after Deductible 50% after Deductible
Outpatient Rehabilitation Facility 30% after Deductible (35 visit annual max) 50% after Deductible (35 visit annual max)
Habilitative Services 30% after Deductible (35 visit annual max) 50% after Deductible (35 visit annual max)
Skilled Nursing Facility 30% after Deductible 50% after Deductible
Prenatal and Postnatal - Office Visit $90 Copay after Deductible 50% after Deductible
Labor and Delivery - Hospital Stay 30% after Deductible 50% after Deductible
BlueOptions Everyday Health Plus 1410P

Plan Information

Annual Out-of-Pocket Maximum (includes deductibles, copays and coinsurance)
Individual: $6,850 / Family: $13,700
Annual Deductible
Individual: $6,100 / Family: $12,200
Coinsurance (%)
30%

Prescription Drugs

Generic Drugs
Preventive - $0
Condition Care Generic - $4 Copay
Low cost: $30 Copay after Deductible
High cost: $30 Copay after Deductible
Preferred Brand Drugs
Condition Care Brand - $23 Copay
Low cost: $45 Copay after Deductible
High cost: $45 Copay after Deductible
Non-Preferred Brand Drugs
Low cost: $160 Copay after Deductible
High cost: $160 Copay after Deductible
Specialty Drugs
Low cost: $200 Copay after Deductible
High cost: $200 Copay 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 visit,
$65 Copay for all other visits
Specialist
$90 Copay after Deductible

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
$0
Basic Dental Care
$0
Major Dental Care
$0
Medically Necessary Orthodontia
$0

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
$600 Copay after Deductible
Urgent Care Center
$250 Copay after Deductible

Hospital and Surgical Care

Ambulatory Surgical Center
30% after Deductible
Outpatient Hospital Facility
30% after Deductible
Inpatient Hospital Facility
30% after Deductible
Physicians Services (all locations)
$0

Other Benefits

Mental/Behavioral Health Outpatient Facility Services
30% after Deductible
Mental/Behavioral Health Inpatient Facility Services
30% after Deductible
Substance Abuse Dependency Outpatient Facility Services
30% after Deductible
Substance Abuse Dependency Inpatient Facility Services
30% after Deductible
Outpatient Rehabilitation Facility
30% after Deductible (35 visit annual max)
Habilitative Services
30% after Deductible (35 visit annual max)
Skilled Nursing Facility
30% after Deductible
Prenatal and Postnatal - Office Visit
$90 Copay after Deductible
Labor and Delivery - Hospital Stay
30% after Deductible

Plan Information

Annual Out-of-Pocket Maximum (includes deductibles, copays and coinsurance)
Individual: $12,500 / Family: $25,000
Annual Deductible
Individual: $12,200 / Family: $24,400
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
$600 Copay 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)
$0

Outpatient Diagnostic Services

Laboratory Services
$0
Basic Imaging (e.g. x-ray, ultrasound)
$4 Copay
Advanced Imaging (e.g. CT/CAT Scan, MRI, MRA)
30% after Deductible

Outpatient Diagnostic Services

Laboratory Services
50% after Deductible
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