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BSP QHDHP
PCB QHDHP
BASE PPO
HMO
BUY-UP PPO
Network
Blue Select Plus
Preferred Care Blue
Preferred-Care Blue
Blue Care
Preferred-Care Blue
Deductible
- Individual
- Family
$2,600
$5,200
$2,600
$5,200
$1,000
$2,000
None
None
$500
$1,000
Coinsurance
0%
0%
20%
0%
20%
Out of Pocket Maximum
- Individual
- Family
In-Network
Out-of-Network
$2,600
$13,000
$5,200
$26,000
In-Network Out-of-Network
$2,600 $5,200
$5,200 $10,400
$4,000
$8,000
$3,000
$7,500
$2,750
$5,500
Physician Office Visits
-
Primary Care Physician
- Specialist
Subject to Deductible
Subject to Deductible
Subject to Deductible
Subject to Deductible
$40
$80
$40
$80
$20
$40
Preventive Care
- Routine Physicals
- Routine Mammogram
- Routine Colonoscopy
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Hospital Services
- Inpatient
- Outpatient surgical
- Hi-Tech Scans
Subject to Deductible
Subject to Deductible
Subject to Deductible
Subject to Deductible
Subject to Deductible
Subject to Deductible
Deductible then 20%
Deductible then 20%
Deductible then 20%
$500 per day up to
$2,500/ calendar
year/person
Deductible then 20%
Deductible then 20%
Deductible then 20%
Emergency Room
Urgent Care
Subject to Deductible
Subject to Deductible
Subject to Deductible
Subject to Deductible
$200 then Ded.
then 20%
$80
$200
$80
$150 then Ded.
then 20%
$40
Prescription Drugs
- Deductible
- Tier 1 Generic
- Tier 2 Preferred
- Tier 3 Non-Preferred
- Mail order (120 day)
Medical Ded. then:
$0
$0
$0
$0
Medical Ded. then:
$0
$0
$0
$0
N/A
$12
$35
$60
$24/$70/$120
N/A
$12
$35
$60
$24/$70/$120
N/A
$12
$35
$60
$24/$70/$120
As a reminder, if you select the Blue Care HMO you will be required to designate a primary care physician on your enrollment form for you and each
dependent you enroll.
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