Group Health Insurance

Base Plan

Blue Choice Comprehensive Major Medical

Buy-Up Plan

Blue Choice Comprehensive Major Medical

Deductible

$1000 Individual/$3000 three or more persons

$500 Individual/$1500 three or more persons

Coinsurance (Member portion for most services)

20% of allowed amounts after deductible has been met; up to $1000 Emp/$3000 Emp & Dependents maximum

20% of allowed amounts after deductible has been met; up to $1000 Emp/$3000 Emp & Dependents maximum

Annual Out-of-Pocket Maximum (includes deductible and coinsurance) Copays do not apply to the annual out-of-pocket amount.

$2000 Individual/$6000 three or more persons.   After the annual out-of-pocket amount has been reached (deductible/coinsurance), eligible benefits will be paid at 100% of the allowed amount for the remainder of the benefit period.

$1500 Individual/$4500 three or more persons.  After the annual out-of-pocket amount has been reached (deductible/coinsurance), eligible benefits will be paid at 100% of the allowed amount for the remainder of the benefit period.

Office Visit Copay (including hearing and eye exam)

$25 Copay

$25 Copay

Out-Patient Lab & X-Ray

Pays at 100% of allowable charges up to a combined maximum of $500 for each covered person, each benefit period (combined benefit period maximum).

Mental Illness & Substance Use Disorders - Inpatient Services (Requires pre-admission certification from New Directions Behavioral Health at 1-800-952-5906)

Mental Illness & Substance Abuse Disorders - Outpatient Services

Eligible Children

Covered to age 26

Covered to age 26

Lifetime Maximum

Unlimited lifetime benefit

Unlimited lifetime benefit

In-Hospital Pre-Admission Certification

Yes*

Yes*

Home Health Care/Hospice

Pays 100% of allowable charges for Home Health Care; Hospice paid 100% with a $5,000 lifetime maximum.

Pays 100% of allowable charges for Home Health Care; Hospice paid 100% with a $5,000 lifetime maximum.

Prescription Drugs - BlueRx Card - RETAIL

The quantity per prescription shall be the greater of a 34-day supply or 100 unit dosage, if defined as a maintenance drug. (Prior authorization and quantity limits may apply)

$5 Generic/$40 brand formulary/$70 brand non-formulary

The quantity per prescription shall be the greater of a 34-day supply or 100 unit dosage, if defined as a maintenance drug. (Prior authorization and quantity limits may apply)

$5 Generic/$35 brand formulary/$60 brand non-formulary

Prescription Drugs - BlueRx Mail (90 day supply)

Prior authorization and quantity limits may apply

2 times retail copay.

Prior authorization and quantity limits may apply

2 times retail copay.