Page 4 - Affiliate Mortgage 2020 Benefit Guide

Affiliate Mortgage Services: September 2020 Open Enrollment

Base Plan Buy Up Plan
Current Renewal Current Renewal
Blue Care Network Blue Care Network Blue Care Network Blue Care Network

Gold $1,000/20% VA Gold $1000 20% VA Platinum 20% VA Platinum 20% VA
Plan Type HMO HMO HMO HMO
Plan Year 2019 2020 2019 2020
In-Network In-Network In-Network In-Network
Deductible
Individual $1,000 $1000 $0 $0
Couple/Family $2,000 $2000 $0 $0
Coinsurance 20% 20% 20% 20%
Coinsurance Max
Individual $2,500 $3500 $1,000 $1,000
Couple/Family $5,000 $7000 $2,000 $2,000
Annual Out of Pocket Max
Individual $6,600 $8150 $6,600 $6600
Couple/Family $13,200 $16300 $13,200 $13200
Physician Copays
Preventive Care Covered 100% No Charge Covered 100% No Charge
Office Visit $20 $20 $25 $25
Specialty Office Visit $40 $40 $35 $35
Virtual Visits $20 $20 $25 $25
Hospital Services
Urgent Care $50 $50 $35 $35
Emergency Room $250 after deductible $250 Copay after deductible $150 $150
Inpatient Hospital 20% after deductible 20% after deductible 20% 20%
Outpatient Hospital 20% after deductible 20% after deductible 20% 20%
Diagnostic Services
Imaging/CT/PET/MRI $150 after deductible $150 Copay after deductible $150 $150
Labs 20% after deductible No Charge 20% No Charge
X-Rays 20% after deductible 20% after deductible 20% 20%
Mental Health $20 $20 $25 $25
Chiropractic $40 $40 $35 $35
Prescription Drugs
Generic $6/$25 $10/$30 $4/$15 $4/$15
Preferred Brand $50 $60 $40 $40
Non-Preferred Brand $80 $80 $80 $80
Preferred Specialty 20%/$200 max 20%/$200 max 20%/$200 max 20% max $200
Non-Preferred Specialty 20%/$300 max 20%/$300 max 20%/$300 max 20% max $300
Effective Date 9/1/2019 9/1/2020 9/1/2019 9/1/2020

Illustrative purposes only. Rates are subject to DIFS and carrier approval.