Page 13 - Demo

Schedule of Benefits
11
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*
Surgery (Outpatient Hospital)
20% after deductible
40% after deductible
20% after deductible
40% after deductible
20% after deductible
40% after deductible
Inpatient Physician Service
20% after deductible
40% after deductible
20% after deductible
40% after deductible
20% after deductible
40% after deductible
Inpatient Hospital Expenses
20% after deductible
40% after deductible
20% after deductible
40% after deductible
20% after deductible
40% after deductible
Outpatient Surgery 20% after deductible
40% after deductible
20% after deductible
40% after deductible
20% after deductible
40% after deductible
Outpatient Diagnostic X-ray and Lab
20% after deductible
40% after deductible
20% after deductible
40% after deductible
20% after deductible
40% after deductible
Emergency Room
20% after deductible
20% after deductible
ER visit 1 - 3: $200 copay then 20% ER visit 4 - 5: $250 copay then 20% ER visit 6+: $300 copay then 20% Non-emergent ER visits subject to copay then 50%
Prescriptions –You Pay
Retail Pharmacy Care
Generic/Preferred/Non-Preferred
(30-day supply 90-day retail available)/ Specialty
Subject to HSA & deductible
deductible
after deductible
deductible
$20/$50/$75/$100***
Subject to HSA & deductible
deductible
after deductible
deductible
$20/$50/$75/$100***
$20/$50/$75/$100 Home Delivery
Generic/Preferred/Non-Preferred
(90-day supply)
Subject to HSA & deductible
deductible
after deductible
deductible
$40/$100/$150***
Subject to HSA & deductible
deductible
after deductible
deductible
$40/$100/$150***
$40/$100/$150 Behavioral Health (BH) and Substance Abuse – You Pay
Inpatient BH (Hospital)
20% after deductible
40% after deductible
20% after deductible
40% after deductible
20% after deductible
40% after deductible
Outpatient Counseling (Professional)
20% after deductible
40% after deductible
20% after deductible
40% after deductible
$35 copay per visit 40% after deductible
Substance Abuse (Professional)
20% after deductible
40% after deductible
20% after deductible
40% after deductible
20% after deductible
40% after deductible
Substance Abuse (Outpatient)
20% after deductible
40% after deductible
20% after deductible
40% after deductible
$35 copay per visit 40% after deductible