Deductible
Out of pocket
Individual Max Out of Pocket
In
$5,000
Out
$10,000
Family Max Out of Pocket
In
$10,000
Out
$20,000
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Coinsurance
Plan pays
In
80%
Out
60%
Subscriber pays
In
20%
Out
40%
Office visits
Primary care physician
In
20% Coinsurance
Out
40% Coinsurance
Quality Blue Primary Care
In
Not Applicable
Out
Not Applicable
Specialist
In
20% Coinsurance
Out
40% Coinsurance
Urgent care
In
20% Coinsurance
Out
40% Coinsurance
Preventative care
In
No Charge
Out
40% Coinsurance
Physical, Speech & Occupational Therapy
In
20% Coinsurance
Out
40% Coinsurance
Mental/Behavioral Health Services
In
20% Coinsurance
Out
40% Coinsurance
If you have a test
Diagnostic test (x-ray, blood work)
In
20% Coinsurance
Out
40% Coinsurance
Imaging (CT/PET scans)
In
20% Coinsurance
Out
40% Coinsurance
Hospitalizations
Inpatient
In
20% Coinsurance
Out
40% Coinsurance
Outpatient
In
20% Coinsurance
Out
40% Coinsurance
Emergency room visits
In
20% Coinsurance
Out
20% Coinsurance
Prescription coverage
Prescription deductible
In
Integrated in Deductible
Out
Integrated in Deductible
Tier 1
In
20%
Out
20%
Tier 2
In
40%
Out
40%
Tier 3
In
Not Applicable
Out
Not Applicable
Tier 4
In
Not Applicable
Out
Not Applicable
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