| Simply Blue 80 | Simply Blue 100 | ||
| In-network plan features | |||
|
Calendar year deductible Amount you pay toward health care before your plan starts to pay (combines medical and drug expenses) |
$4,000 $8,000
|
$5,000 $7,500 $10,000 | |
|
Out-of-pocket (OOP) maximum After this amount is reached, your plan pays 100% of covered expenses Copays do not apply to the out-of-pocket maximum (combines medical and drug expenses) |
$6,500 $10,500 |
$5,000 $7,500 $10,000 |
|
|
Coinsurance Percentage that you pay after deductible |
You pay 20% after deductible | You pay 0% after deductible | |
| In-network benefits | |||
|
Prescription drugs (GenRx
formulary) 31-day supply. 90-day supply available through 90dayRx program at participating retail pharmacies or by PrimeMail 1 |
Covered
|
Covered
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Office visits In a health care professional offi ce, urgent care clinic, or retail clinic for an illness or injury including allergy services, lab and diagnostic imaging/X-ray services |
Covered Plan pays first $300, then you pay 20% after deductible |
Covered Plan pays first $500, then you pay 0% after deductible |
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All other professional
services in the offi ce Immunizations, surgery, anesthesia, ear washing, wart removal, inpatient and outpatient hospital visits |
Covered You pay 20% after deductible |
Covered You pay 0% after deductible |
|
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Preventive care Includes routine physicals, eye exams, cancer screening, immunizations |
Covered Plan pays first $250, then you pay 20% after deductible |
Covered Plan pays first $250, then you pay 0% after deductible |
|
| Inpatient/outpatient lab and diagnostic imaging/X-ray services |
Covered You pay 20% after deductible |
Covered You pay 0% after deductible |
|
| Emergency room | |||
| Inpatient/outpatient hospital services | |||
| Ambulance | |||
| Medical supplies | |||
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Chiropractic care Maximum of $500 per person per calendar year |
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| Occupational, physical, speech therapy | |||
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Home health care Up to $25,000 per person per calendar year |
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| Well-child services to age 6 Immunizations to age 18 |
Covered You pay 0% (no deductible) |
Covered You pay 0% (no deductible) |
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Prenatal care |
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| Maternity labor, delivery, post-delivery care and maternity complications | Not Covered | Not Covered | |
| Lifetime maximum benefit | $5 million per person all networks | $5 million per person all networks | |
| Out-of-network plan features | |||
|
Calendar year deductible Separate from in-network deductible (combines medical and drug expenses) |
$8,000 $16,000 |
$10,000 $15,000 $20,000 |
|
|
Out-of-pocket maximum Separate from in-network out-of-pocket maximum (combines medical and drug expenses) |
$13,000 $21,000 |
$20,000 $30,000 $40,000 |
|
| Coinsurance | You pay 40% after deductible | You pay 20% after deductible | |
| Coverage
for substance abuse is included in the contract. You
may choose to exclude substance abuse coverage, in which case
your premium will be slightly reduced. Dependents may not be added to this plan, but they can apply for their own Simply Blue plan. This is only a summary. Your contract will provide a detailed description of what is and is not covered. Services not covered include childbirth and delivery, private duty nursing, custodial care or rest cures, bariatric surgery, infertility, eyewear, dental services, services that are experimental, not medically necessary or received while on military duty. Preexisting conditions you had during the six months before your enrollment date are not covered. This limit applies for 12 months. Prior continuous coverage without a gap in coverage greater than 63 days counts toward reducing the 12-month period. Consumer Price Index Annual Adjustment: The deductible, copay and out-of-pocket maximum amounts are subject to annual adjustments. These adjustments are based on the medical care component of the Consumer Prices Index (CPI) published by the U.S. Department of Labor. These annual adjustments are effective on the annual renewal date How cost sharing is calculated: Copays are fl at fees you pay at the time you receive a service. Coinsurance is the percentage of charges you pay for a service. It’s based on the allowed amount. Deductible is the portion of the allowed amount you must pay. Allowed amount is the negotiated amount that participating providers have agreed to accept as full payment at the time your claim is processed. If you see a provider who doesn’t participate with Blue Cross, you are responsible for charges greater than the allowed amount, in addition to applicable coinsurance. 1 PrimeMail is from Prime Therapeutics, an independent company that provides pharmacy benefit management services. |
