|
|
BlueSelections Premier |
| Lifetime benefit maximum |
$2 million per individual |
| Deductibles |
-
$500 per person
-
$1,000 per person
-
$2,500 per person
-
$5,000 per person
-
$7,500 per person
|
-
$1,500 family
-
$3,000 family
-
$7,500 family
-
$15,000 family
$22,500 family
|
Annual Maximum Coinsurance
(maximum of three coinsurance maximums per contract) |
In-Network:
$4,000 |
Out-Of-Network:
$8,000 |
| Preventative Care Services |
| Adult and Child Immunizations |
100% after $20 copay, not subject to the deductible |
100% after $40 copay, not subject to the deductible |
| Annual Women's Exams includes PAP smear and mammogram |
100% after $20 copay, not subject to the deductible |
100% after $40 copay, not subject to the deductible |
| Annual Men's Exams includes PSA test |
100% after $20 copay, not subject to the deductible |
100% after $40 copay, not subject to the deductible |
| Well-baby exam to age 2 |
100% after $20 copay, not subject to the deductible |
100% after $40 copay, not subject to the deductible |
| Well Child |
100% after $20 copay, not subject to the deductible |
100% after $40 copay, not subject to the deductible |
| |
| Dental Services |
Individual Dentacare (optional) |
Office Visit
Physician services |
In-Network:
We pay 100% after $20 copay
not subject to deductible |
Out-Of-Network:
We pay 100% after $40 copay
not subject to deductible |
Hospitalizations
Hospital Facility
(Inpatient & Outpatient) |
In-Network:
We pay 80% |
Out-Of-Network:
We pay 60% |
| Emergency Room |
We pay 80% after $100 copay |
| Laboratory and Radiology Services |
In-Network:
We pay 80% |
Out-Of-Network:
We pay 60% |
| Maternity |
In-Network:
We pay 80% |
Out-Of-Network:
We pay 60% |
Vision
Eye Exam (Refractions) |
IN-NETWORK:
We pay 100% after $20 copay. Limited to one eye exam (refraction) per
calendar year. Not subject to deductible. |
OUT-OF-NETWORK:
We pay 60%. Limited to one eye exam (refraction) per calendar year. Not
subject to deductible. |
| Hardware (Glasses, Lenses, Contacts) |
We pay 100%; Hardware limited to $250 per calendar year.
Not subject to deductible. |
| Prescription Drugs |
Generic: We pay 100% after $10 copay
We pay 50% for all other charges,
No annual limit |
|
Additional Benefits |
| Additional Accident Coverage |
Deductible waived for accidental injuries
treated within 90 days of injury date |
| Accidental death |
Provide $25,000 for you and your enrolled
adult spouse, $5,000 for each enrolled dependent or child subscriber |
| |
Plan Updates 
