Page 12 - Demo

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Schedule of Benefits
FULL-TIME AND PART-TIME (30 OR OR MORE HOURS PER WEEK)
BlueEdge HSASM Option 1 BlueEdge HSASM Option 2
Blue Choice Select PPOSM & PPO PPO Plan
Coverage
In-Network
Out-of- Network*
In-Network
Out-of- Network*
In-Network
Out-of- Network*
Health Account HCSC Provided
Individual/Family
$500/$1 000
$500/$1 000
Not applicable
Calendar Year Deductible
Individual/ Family
$1 500/$3 000
family aggregate
$2 500/$5 000
family aggregate
$750/ $1 500 $1 200/ $2 400
Out-of-Pocket Maximum
(includes deductible) Individual/ Family
$3 000/ $6 000
$5 500 /$11 000
$6 250 /$12 500 $12 500/ $25 000
$4 000/ $8 000
$5 200/ $10 400
Penalty for Failure to Pre-Authorize
$500 $500 $500 Penalty for Failure to Call a a a a Health Advocate**
$200 $200 $200 Lifetime Health Care
Maximum
Unlimited
Unlimited
Unlimited
Physician Services –You Pay
Office Visit
Non-Specialist/Specialist
20% after deductible
40% after deductible
20% after deductible
40% after deductible
$35/$50 copay per visit 40% after deductible
Virtual Visits
$44 copay subject to deductible
and coinsurance
$44 copay subject to deductible
and coinsurance
$30 copay Chiropractic & Muscle Manipulation
20% after deductible
40% after deductible
20% after deductible
40% after deductible
$50 copay 40% after deductible
50 visit limit 50 visit limit 50 visit limit Physical Therapy
20% after deductible
40% after deductible
20% after deductible
40% after deductible
$50 copay 40% after deductible
Preventive Services Non-Specialist/Specialist
0% no deductible
Not Covered
0% no deductible
Not Covered
$0 no deductible
40% after deductible
Well-Baby Care
Non-Specialist/Specialist
0% no deductible
Not Covered
0% no deductible
Not Covered
$0 copay per visit 40% after deductible
Immunizations
Non-Specialist/Specialist
0% no deductible
Not Covered
0% no deductible
Not Covered
$0 copay per visit 40% after deductible
Diagnostic X-ray and Lab
Non-Specialist/Specialist
20% after deductible
40% after deductible
20% after deductible
40% after deductible
20% after deductible
40% after deductible
*
In addition to coinsurance
the the the the member’s responsibility includes the the the the difference if if any between the the the the in-network payment allowance and the the the the provider’s charge ** Must contact a a a a a a a a a a a a a a a health advocate prior to scheduling imaging & CT scans x-rays joint replacement bariatric surgery musculoskeletal IP/OP procedures breast reductions (medically necessary) ***
Certain preventive medications are
available at at at copayment levels without satisfying the deductible