Employer groups may select from a choice of deductible options.
|Basic Plan Summary||Member Pays|
|Deductible (Per group anniversary benefit period)||$3,000/$6,000; $5,000/$10,000
|Coinsurance (Member portion for most services)||$0|
|Maximum Out-of-Pocket (Includes copays, deductible and coinsurance where applicable)||$6,350/$12,700 individual/two-or-more persons.
After the maximum out-of-pocket amount has been reached, eligible benefits will be paid at 100% of the allowed amount for the remainder of the benefit period.
|Doctor's Office Visits|
|Home and office visits||Subject to deductible|
|Telehealth visits||Subject to deductible|
|Preventive care as defined by the Affordable Care Act||These services are paid at 100% of the allowable charge.
Some of the services include:
|Prescription drugs & mail order||The quantity per prescription is a 30-day pharmacy supply
or 90-day mail order supply.
Integrated Drugs (Pharmacy Submitted) until deductible met, then covered with BlueRx Card $15/$50/$75/$150/20% up to $250. Mail order is 2½ x copay with ResultsRx Formulary.
Must use designated specialty pharmacy for all specialty prescriptions.
|Emergency medical transportation||Subject to deductible|
|Inpatient surgery physician/surgical|
|Inpatient facility fee|
|Outpatient surgery physician/surgical|
|Outpatient lab and radiology (Includes advanced imaging)|
|Accidental Injury Services|
|Outpatient rehabilitation||Subject to deductible|
|Home social work visits|
|Mental/behavioral health - inpatient services
Requires pre-admission certification from New Directions Behavioral Health at 1-800-952-5906
|Subject to deductible|
|Mental/behavioral health - outpatient services|
|Eligible dependents||Covered to age 26|
Exclusions: Following is a list of common non-covered services. For a complete list of limitations and exclusions, refer to your certificate.
Duplicate benefits provided under federal, state or local laws, regulations or programs except Medicaid; services involving cosmetic or reconstructive surgery (except as stated in the contract); charges for personal items; convalescent or custodial care or rest cure; all keratotomy procedures; blood or payments to donors of blood; any service or supply related to the medical management of obesity, except services covered as preventive health benefits; services or supplies related to sex transformations; services related to the reversal of sterilization procedures; any medically-aided insemination procedure; charges for services by immediate relatives or by members of the household; acupuncture and admission for acupuncture; medically unnecessary services and admissions; services covered and payable under any medical expense payment provision of any automobile insurance policy; mental illness or substance use disorder services provided by a non-eligible provider; services, supplies or treatments not specifically listed as covered in the member’s contract.
Drug coverage limitation: Generic drugs are mandatory if available unless physician prescribes a brand drug.
Additional Program Information
Triple Option Plan
The Triple Option Plan is available to large groups with this product. The plan offers employees one of three out-of-pocket choices annually within the High Deductible Health Plan benefit program. The employer must contribute at least 25 percent of the employee-only premium amount for the highest out-of-pocket option. This stabilizes the group's base and gives the employees the option to "buy up" to a better level of coverage, based on their personal insurance needs.
Contact us to learn more about the features of BlueEdge High Deductible Health Plan.