Medical
Medical coverage provides healthcare protection for you and your family. You can visit any provider, but in-network doctors offer the highest level of benefits and lower out-of-pocket costs by charging reduced, contracted rates. Out-of-network providers set their own fees, so you may be responsible for charges above the Reasonable and Customary (R&C) limits. Preventive care—such as physical exams, flu shots, and screenings—is covered at 100% when you use in-network providers. The main differences between plan options are how much you pay per paycheck and what you pay when you receive care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Blue Preferred 14
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,000/$2,000
Out-of-Pocket Max (Individual/Family)
$3,500/$7,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$20 copay
Emergency Room
$0*
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$60 copay
Specialty
50% to a max of $100
Non-Preferred Specialty
50% to a max of $150
Mail-Order Rx (Up to 90-Day Supply)
Generic
$30 copay
Preferred Brand
$70 copay
Non-Preferred Brand
$120 copay
Specialty
$XX
*After deductible
Out-of-Network
Deductible (Individual/Family)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$7,000/$14,000
Preventive Care
20%*
Primary Care Visit
20%*
Specialist Visit
20%*
Urgent Care
20%*
Emergency Room
$0*
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$60 copay
Specialty
Not covered
Non-Preferred Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not Covered
Preferred Brand
Not Covered
Non-Preferred Brand
Not Covered
Plan Cost
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX
BlueChoice Advantage 11
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,500/$3,000
Out-of-Pocket Max (Individual/Family)
$4,500/$9,000
Preventive Care
No Cost
Primary Care Visit
$20 copay
Specialist Visit
$40 copay
Urgent Care
$50 copay
Emergency Room
20%*
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$60 copay
Specialty
50% to a max of $100
Non-preferred Specialty
50% to a max of $100
Mail-Order Rx (Up to 90-Day Supply)
Generic
$30 copay
Preferred Brand
$70 copay
Non-Preferred Brand
$120 copay
*After Deductible
Out-of-Network
Deductible (Individual/Family)
$3,000/$6,000
Out-of-Pocket Max (Individual/Family)
$9,000/$18,000
Preventive Care
$0*
Primary Care Visit
40%*
Specialist Visit
40%*
Urgent Care
$50 copay
Emergency Room
20%*
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$60 copay
Specialty
Not covered
Non-preferred Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Cost
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX
BlueChoice Advantage 4
Benefit Highlights
In-Network
Deductible (Individual/Family)
$5,000/$10,000
Out-of-Pocket Max (Individual/Family)
$7,350/$14,700
Preventive Care
$0
Primary Care Visit
$30 copay
Specialist Visit
$60 copay
Urgent Care
$100 copay
Emergency Room
$250 copay*
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$60 copay
Specialty
50% to a max of $150
Non-preferred Specialty
50% to a max of $150
Mail-Order Rx (Per 90-Day Supply)
Generic
$30 copay
Preferred Brand
$70 copay
Non-Preferred Brand
$120 copay
*After Deductible
Out-of-Network
Deductible (Individual/Family)
$10,000/$20,000
Out-of-Pocket Max (Individual/Family)
$15,000/$30,000
Preventive Care
$0*
Primary Care Visit
20%*
Specialist Visit
20%*
Urgent Care
$100 copay
Emergency Room
$250 copay*
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$60 copay
Specialty
Not covered
Non-Preferred Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Cost
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX