IN-NETWORK
BENEFITS |
BluePrint PPO MIBPP2070 |
BlueEdge HSA MIEEA3093 |
Blue Advantage HMO MIBAV2110 |
Deductible |
Individual: $1,500Family: $4,500 |
Individual: $3,500
|
None |
Coinsurance |
You pay 20% (after deductible)
|
You pay 20% (after deductible)
|
You pay 00%Plan pays 100% |
Out of Pocket Maximum |
Individual: $3,500
|
Individual: $5,800
|
Individual: $3,000
|
Office Visit Copay |
$30 PCP$50 Specialist$0 TelehealthUrgent Care- You pay 20% coinsurance (after deductible)
|
20% coinsurance PCP20% coinsurance Specialist$0 Telehealth20% coinsurance Urgent Care |
$40 PCP$60 Specialist$0 TelehealthUrgent Care-Primary Care: $40copay Specialist: $60 copay |
Preventive Care, Screening, Immunization |
You pay $0
|
You pay $0
|
You pay $0
|
Emergency Room Copay |
You pay 20% coinsurance (after deductible)
|
20% coinsurance |
You pay $350 copay (waived if admitted) |
Prescription DrugDeductibleCost Per Tier |
Retail (Up to 30-day supply)In-networkGeneric Preferred: No chargeGeneric Non preferred: $10 copayBrand Preferred: $50 copayBrand Non preferred: $100 copayPreferred/Non preferred Specialty: $150 / $250 copay |
Retail (Up to 30-day supply)
|
Retail (Up to 30-day supply)In-networkGeneric Preferred: No chargeGeneric Non preferred: $10 copayBrand Preferred: $35 copayBrand Non preferred: $75 copayPreferred/Non preferred Specialty: $150 / $250Mail (Up to 30-day supply)
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Hospitalization |
Inpatient In-network:
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Inpatient In-network:
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Inpatient In-network:
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