| | | |
| Services | PPOBlue, An Individual Comprehensive
Major Medical Preferred-Provider
High-Deductible Health Plan;
$3,500 Individual/$7,000 Family Deductible;
Medically Underwritten | DirectBlue, An Individual Comprehensive Major Medical Preferred-Provider Health Plan; $500 Individual/$1,500 Family Deductible; Medically Underwritten |
| | Network | Out-of-Network | Network | Out-of-Network |
| Benefit Period | Contract Year | Contract Year | Contract Year | Contract Year |
| Type of Coverage | Medically Underwritten | Medically Underwritten | Medically Underwritten | Medically Underwritten |
| Deductible - Individual | $3,500
Includes out-of-network benefits | Choice of network deductible applies to out-of-network benefits | $500 | $500 |
| Deductible - Family | $7,000
Includes out-of-network benefits
Family deductible must be met in full before benefits are payable | Choice of network deductible applies to out-of-network benefits | $500 per person with a maximum of $1500 | $500 per person with a maximum of $1,500 |
| Out of Pocket Maximum (does not include deductible) - Individual | $1,500 | $3,000 | $1,500 for network and out-of-network covered services combined | $1,500 for network and out-of-network covered services combined |
| Out of Pocket Maximum (does not include deductible) - Family | $3,000 | $6,000 | $4,500 for network and out-of-network covered services combined | $4,500 for network and out-of-network covered services combined |
| Coinsurance (only applied after any applicable deductibles have been met) | 90% | 70% | 90% | 70% |
| Lifetime Policy Maximum | $5,000,000
Includes out-of-network payments | $300,000
Included as part of network maximum | $5,000,000
Includes out-of-network payments | $300,000
Included as part of network maximum |
| Benefit Period Maximum | $1,000,000
Includes out-of-network payments | Included as part of network maximum | $1,000,000
Includes out-of-network payments | Included as part of network maximum |
| Hospital Facility Expense - Inpatient
(includes Maternity) | 90%
Includes maternity | 70%
Includes maternity
Limited to 90 days/benefit period | 90%
Includes maternity | 70%
Includes maternity |
| Emergency Room Care | 90% | 90% | 90% after $40 copayment
(waived if admitted) | 90 % after $40 copayment (waived if admitted) |
| Office/Home Visits | 90% | 70% | 90% | 70% |
| Medical/Surgical Expenses
(except office visits) | 90% | 70% | 90% | 70% |
| Preventive Care | Routine Physicals, Gynecological Exam, Pap Test, Mammogram and Pediatric Immunizations.
Deductible does not apply - 90% | Not Covered | Routine Physical and Mammogram
Gynecological Exam and Pap Test
Pediatric Care
Pediatric Immunizations
Adult Immunizations
90% - deductible does not apply | Not Covered |
| Diagnostic Services
( X-ray, lab, other tests) | 90% | 70% | 90% | 70% |
| Physical Medicine | 90%
15 visits per contract year | 70%
Included as part of network visits | 90%
15 visits per calendar year | 70%
Included as part of network visits |
| Occupational and Speech Therapy | 90%
Combined 15 visits per contract year | 70%
Included as part of network visits | 90%
Combined 15 visits per calendar year | 70%
Included as part of network visits |
| Spinal Manipulations | 90%
10 visits per contract year | 70%
Included as part of network visits | 90%
10 visits per calendar year | 70%
Included as part of network visits |
| Mental Health Services | Not Covered | Not Covered | Not Covered | Not Covered |
| Substance Abuse - Rehabilitation | Not Covered | Not Covered | Not Covered | Not Covered |
| Substance Abuse - Detoxification | Not Covered | Not Covered | Not Covered | Not Covered |
| Prescription Drug | 90%
$50,000 contract year maximum | Not Covered | $100 deductible per calendar year
$10 generic, $20 brand
$50,000 calendar year maximum | Not Covered |
| Discounts on Health-Related Services - Fitness Centers & Spas
- Massage Therapy
- Nutritional Counseling
- Personal Trainers
| Covered | Covered | Covered | Covered |
| Blues On Call
-Health Information and Support Toll-Free Hotline | Covered | Covered | Covered | Covered |
| Vision* | Not Covered | Not Covered | - Eye exam every two years - 100% -- Deductible Does Not Apply
- Discounts on lenses and frames, non-prescription sunglasses & Laser Vision Correction
- Davis Vision Provider Network Only
- Benefit does not apply towards deductible
| None |
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