|
BluePreferred
Saver
$1,500
-
100% |
In-Network |
Out-Of-Network |
 |
Annual
Deductible
|
Individual
Coverage:
$1,500
Family
Coverage:
$3,000 |
Individual
Coverage:
$2,000
Family
Coverage:
$3,500 |
 |
Annual
Out-Of-Pocket
Limit
|
Individual
Coverage:
$5,000
Family
Coverage:
$10,000 |
Individual
Coverage:
$10,000
Family
Coverage:
$20,000 |
 |
Lifetime
Maximum
|
$3,000,000 |
$3,000,000 |
 |
Office
Visits
|
No
Charge
after
deductible
is
met |
50% |
 |
Prescription
Drugs
|
No
Charge
after
deductible
is
met |
50% |
 |
Laboratory
and
Radiology
|
No
Charge
after
deductible
is
met |
50% |
 |
Annual
Physical
Exam
|
No
Charge |
Not
Covered |
 |
Annual
OB-GYN
Exam
|
No
Charge |
Not
Covered |
 |
Prenatal
/
Postnatal
Maternity
|
Not
Applicable |
Not
Applicable |
 |
Well
Baby
Care
|
No
Charge |
Not
Covered |
 |
Outpatient
Surgery
|
No
Charge
after
deductible
is
met |
50% |
 |
Emergency
Room
|
No
Charge
after
deductible
is
met
plus
$150
(waived
if
admitted) |
No
Charge
after
deductible
is
met
plus
$150
(waived
if
admitted) |
 |
Ambulance
|
No
Charge
after
deductible
is
met |
No
Charge
after
deductible
is
met |
 |
Home
Health
Care
|
No
Charge
after
deductible
is
met
(Up
to 3
visits
of 2
hours
or
less
per
day) |
50%
(Up
to 3
visits
of 2
hours
or
less
per
day) |
 |
Mental
Health
Services
|
See
benefits
contract |
See
benefits
contract |
 |
Chiropractic
Care
|
No
Charge
after
deductible
is
met |
50% |
 |
Acupuncture
/
Acupressure
|
Not
Covered |
Not
Covered |
 |
Inpatient
Co-payment
|
No
Charge
after
deductible
is
met |
50% |
|
Maternity
Care |
Not
Covered |
Not
Covered
|
 |
Inpatient
Mental
Health |
No
Charge
after
deductible
(2
admit,
up
to a
combined
total
of
30
days.
$25,000
maximum
benefit
per
person) |
50%
(2
admissions,
up
to a
combined
total
of
30
days.
$25,000
maximum
benefit
per
person) |
 |
Chemical
Dependency
|
See
benefits
contract |
See
benefits
contract |