Deductible
Out of pocket
Individual Max Out of Pocket
In
$4,100
Out
$8,200
Family Max Out of Pocket
In
$8,200
Out
$16,400
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Coinsurance
Plan pays
In
100%
Out
80%
Subscriber pays
In
0%
Out
20%
Office visits
Primary care physician
In
0% After Ded.
Out
20% After Ded.
Quality Blue Primary Care
In
Not Applicable
Out
Not Applicable
Specialist
In
0% After Ded.
Out
20% After Ded.
Urgent care
In
0% After Ded.
Out
20% After Ded.
Preventative care
In
No Charge
Out
20%
Physical, Speech & Occupational Therapy
In
0% After Ded.
Out
20% After Ded.
Mental/Behavioral Health Services
In
0% After Ded.
Out
20% After Ded.
If you have a test
Diagnostic test (x-ray, blood work)
In
0% After Ded.
Out
20% After Ded.
Imaging (CT/PET scans)
In
0% After Ded.
Out
20% After Ded.
Hospitalizations
Inpatient
In
0% After Ded.
Out
20% After Ded.
Outpatient
In
0% After Ded.
Out
20% After Ded.
Emergency room visits
In
0% After Ded.
Out
0% After Ded.
Prescription coverage
Prescription deductible
In
Integrated in Deductible
Out
Integrated in Deductible
Tier
In
0% After Ded.
Out
0% After Ded.
Tier 2
In
20% After Ded.
Out
20% After Ded.
Tier 3
In
Not applicable
Out
Not applicable
Tier 4
In
Not applicable
Out
Not applicable
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