| BluePreferred Saver $5,000 - 100% |
In-Network |
Out-Of-Network |
 |
Annual Deductible |
Individual Coverage: $5,000 Family Coverage: $10,000 |
Individual Coverage: $5,500 Family Coverage: $10,500 |
|
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 |
