Blue Choice AffordaBlue

 

Employer groups may select from a choice of deductible options.

 

Basic plan summary

Member pays

Deductible (per group anniversary benefit period)

$500/$1,500; $1,000/$3,000; $2,000/$6,000; individual/ three-or-more persons

Coinsurance (member portion for most services)

20% of allowed amounts after deductible has been met

Coinsurance maximum

$1,000/$3,000 individual/ three-or-more persons

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 (includes eye exam)

$25 office visit copay for first five visits (15 visits for three-or-more persons) then subject to deductible/coinsurance

Telemedicine visits

$25 office visit copay for first five visits (15 visits for three-or-more persons) then subject to deductible/coinsurance

Preventive care as defined by the Affordable Care Act

These services are paid at 100% of the allowable charge. 
Some of the services include:

  • Routine screenings
  • Preventive immunizations
  • Well-woman visits/screenings
  • Contraceptive methods

Drug coverage

Prescription drugs and mail order

The quantity per prescription shall be the greater of a 34-day supply or 100 unit dosage, if defined as a maintenance drug. 

BlueRx Card $100/$300 then 50% coinsurance; Mail order is subject to retail deductible/coinsurance. 

Must use designated specialty pharmacy for all specialty prescriptions.

Medical services

Emergency medical transportation

Subject to deductible/coinsurance

Inpatient surgery physician/surgical

Inpatient facility fee

Outpatient surgery physician/surgical

Outpatient lab and radiology (includes advanced imaging)

Pays at 100% to a combined maximum of $300 for each covered person ($900 for three-or-more persons), each benefit period then subject to deductible/coinsurance

Emergency room

Subject to deductible/coinsurance

Accidental injury services

$50 copay for first claim received within 60 days of the injury. 
This only applies to the outpatient professional provider visit. 
All other services subject to deductible and coinsurance.

Recovery/special needs

Outpatient rehabilitation

Subject to deductible/coinsurance

Hospice

Home social work visits

Mental health

Mental/behavioral health – inpatient services 
Requires pre-admission certification from New Directions Behavioral Health at (800)952-5906

Subject to deductible/coinsurance

Mental/behavioral health – outpatient services

$25 office visit copay for first five visits (15 visits for three-or-more persons) then subject to deductible/coinsurance

Other

Lifetime maximum

Unlimited

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.

Optional Benefits:

Additional program information

  • Inpatient admissions – Pre-admission certification is required for all planned inpatient admissions.
  • Benefit period – The 12-month period based on the group anniversary month.
  • Waiting period – Businesses select a waiting period option.

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 AffordaBlue 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.

More information 
Contact a representative to learn more about the features of Blue Choice AffordaBlue.