Deductible
Out of pocket
Individual Max Out of Pocket
In
$5,250
Out
$10,500
Family Max Out of Pocket
In
$10,500
Out
$21,000
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Coinsurance
Plan pays
In
80%
Out
60%
Subscriber pays
In
20%
Out
40%
Office visits
Primary care physician
In
$40 Copay
Out
40% Coinsurance
Quality Blue Primary Care
In
Not Applicable
Out
Not Applicable
Specialist
In
$55 Copay
Out
40% Coinsurance
Urgent care
In
$55 Copay
Out
40% Coinsurance
Preventative care
In
No Charge
Out
40% Coinsurance
Physical, Speech & Occupational Therapy
In
20% Coinsurance
Out
40% Coinsurance
Mental/Behavioral Outpatient Services
In
$40 Copay / office visit and 20% Coinsurance other outpatient services
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
None
Out
None
Tier 1
In
$15 Copay
Out
$15 Copay
Tier 2
In
$40 Copay
Out
$40 Copay
Tier 3
In
$70 Copay
Out
$70 Copay
Tier 4
In
10% Coinsurance up to $150 per prescription
Out
10% Coinsurance up to $150 per prescription
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