| High Deductible* | Key Advantage 250** | Key Advantage 500** | ||||||
|---|---|---|---|---|---|---|---|---|
| Plan Year Deductible | ||||||||
| In-Network | In-Network | In-Network | ||||||
| One Person | Two People | Family | One Person | Two People | Family | One Person | Two People | Family |
| $2,800 | See Family | $5,600 | $250 | See Family | $500 | $500 | See Family | $1,000 |
| Out-of-Network | Out-of-Network | Out-of-Network | ||||||
| – | – | – | One Person | Two People | Family | One Person | Two People | Family |
| Deductible is combined for In-Network and Out-of-Network Services. | $500 | See Family | $1,000 | $1,000 | See Family | $2,000 | ||
| Plan Year Out-of-pocket Expense Limit | ||||||||
| In-Network | In-Network | In-Network | ||||||
| One Person | Two People | Family | One Person | Two People | Family | One Person | Two People | Family |
| $5,000 | See Family | $10,000 | $3,000 | See Family | $6,000 | $4,000 | See Family | $8,000 |
| Out-of-Network | Out-of-Network | Out-of-Network | ||||||
| One Person | Two People | Family | One Person | Two People | Family | One Person | Two People | Family |
| $10,000 | See Family | $20,000 | $5,000 | See Family | $10,000 | $7,000 | See Family | $14,000 |
| Out-of-Network Benefits | ||||||||
| Yes. Once you meet the combined deductible you pay 40% coinsurance for medical, behavioral health and prescription drug services from Out-of-Network providers. | Yes. Once you meet the out-of-network deductible, you pay 30% coinsurance for medical behavioral health services. Copayments do not apply to medical and behavioral health services. Copayments and coinsurance for routine vision, outpatient prescription drugs and dental services will still apply | |||||||
| Medical Care When Traveling (BlueCard) | ||||||||
| Included | ||||||||
| Lifetime Maximum | ||||||||
| Unlimited | ||||||||
Covered Services
| High Deductible | Key Advantage 250 | Key Advantage 500 | ||||||
|---|---|---|---|---|---|---|---|---|
| Ambulance Travel | ||||||||
| 20% coinsurance after deductible | ||||||||
| Autism Spectrum Disorder (2 years through 10 years) | ||||||||
| 20% coinsurance after deductible | Copayment/coinsurance determined by service received | |||||||
| Behavioral Health and EAP | ||||||||
| Facility Services (Inpatient Treatment) | ||||||||
| 20% coinsurance after deductible | $400 copayment per stay | 20% coinsurance after deductible | ||||||
| Professional Provider Services (Inpatient Treatment) | ||||||||
| 20% coinsurance after deductible | $0 | |||||||
| Outpatient Professional Provider Visits | ||||||||
| 20% coinsurance after deductible | $20 copayment | $25 copayment | ||||||
| Employee Assistance Program (EAP) - 4 visits per issue (per plan year) | ||||||||
| $0 | ||||||||
| Dental Care | ||||||||
| Preventative Dental Option (diagnostic and preventative services only for lower premium) | ||||||||
| $0 | ||||||||
| Comprehensive Dental Option (for higher premium | ||||||||
| Dental Plan Year Deductible | ||||||||
| One Person | Two People | Family | ||||||
| $25 | $50 | $75 | ||||||
| Plan Year Maximum (Except Orthodontics) | ||||||||
| $1500 | ||||||||
| Preventative Dental Care | ||||||||
| $0 | ||||||||
| Primary Dental Care | ||||||||
| 20% coinsurance after dental deductible | ||||||||
| Major Dental Care | ||||||||
| 50% coinsurance after dental deductible | ||||||||
| Orthodontic Services (Includes Adult Ortho) | ||||||||
| 50% coinsurance, no dental deductible, with $1,500 lifetime maximum | ||||||||
| Diabetic Education | ||||||||
| 20% coinsurance after deductible | $0 | |||||||
| Diabetic Equipment | ||||||||
| 20% coinsurance after deductible | ||||||||
| Diabetic Supplies (See Outpatient Prescription Drugs) | ||||||||
| Diagnostic Tests and X-rays (for specific conditions or diseases at a doctor's office, emergency room or outpatient hospital department) | ||||||||
| 20% coinsurance, after deductible | ||||||||
| Doctor Visits - on an Outpatient Basis | ||||||||
| Primary Care Physicians | ||||||||
| 20% coinsurance after deductible | $20 copayment | $25 copayment | ||||||
| Specialty Care Providers | ||||||||
| 20% coinsurance after deductible | $35 copayment | $40 copayment | ||||||
| Early Intervention Services | ||||||||
| 20% coinsurance after deductible | Copayment/coinsurance determined by service received | |||||||
| Emergency Room Visits | ||||||||
| Facility Services | ||||||||
| 20% coinsurance after deductible | $350 copayment per visit (waived if admitted to hospital) | 20% coinsurance after deductible | ||||||
| Primary Care Physicians (Professional Provider Services) | ||||||||
| 20% coinsurance after deductible | $20 copayment | $25 copayment | ||||||
| Specialty Care Providers (Professional Provider Services) | ||||||||
| 20% coinsurance after deductible | $35 copayment | $40 copayment | ||||||
| Diagnostic Tests and X-rays | ||||||||
| 20% coinsurance after deductible | ||||||||
| Home Health Services (90 visit plan year limit per member) | ||||||||
| 20% coinsurance after deductible | $0 | |||||||
| Home Private Duty Nurse's Services | ||||||||
| 20% coinsurance after deductible | ||||||||
| Hospice Care Services | ||||||||
| 20% coinsurance after deductible | $0 | |||||||
| Hospital Services (Inpatient Treatment) | ||||||||
| Facility Services | ||||||||
| 20% coinsurance after deductible | $400 copayment per stay | 20% coinsurance after deductible | ||||||
| Primary Care Physicians (Professional Provider Services) | ||||||||
| 20% coinsurance after deductible | $0 | |||||||
| Specialty Care Providers (Professional Provider Services) | ||||||||
| 20% coinsurance after deductible | $0 | |||||||
| Hospital Services (Outpatient Treatment) | ||||||||
| Facility Services | ||||||||
| 20% coinsurance after deductible | $150 copayment | 20% coinsurance after deductible | ||||||
| Primary Care Physicians (Professional Provider Services) | ||||||||
| 20% coinsurance after deductible | $20 copayment | $25 copayment | ||||||
| Specialty Care Providers (Professional Provider Services) | ||||||||
| 20% coinsurance after deductible | $35 copayment | $40 copayment | ||||||
| Diagnostic Tests and X-rays | ||||||||
| 20% coinsurance after deductible | ||||||||
| LiveHealth Online (Online Doctor Visit) | ||||||||
| Determined by services received | $0 | |||||||
| Maternity | ||||||||
| Primary Care Physicians (Professional Provider Services - Prenatal & Postnatal Care) | ||||||||
| 20% coinsurance after deductible | $20 copayment | $25 copayment | ||||||
| Specialty Care Providers (Professional Provider Services - Prenatal & Postnatal Care) | ||||||||
| 20% coinsurance after deductible | $35 copayment If your doctor submits one bill for delivery, prenatal and postnatal care services, there is no copayment required for physician care. If your doctor bills for these services separately, your payment responsibility will be determined by the services received. | $40 copayment If your doctor submits one bill for delivery, prenatal and postnatal care services, there is no copayment required for physician care. If your doctor bills for these services separately, your payment responsibility will be determined by the services received. | ||||||
| Primary Care Physicians (Delivery) | ||||||||
| 20% coinsurance after deductible | $0 | $0 | ||||||
| Specialty Care Providers (Delivery) | ||||||||
| 20% coinsurance after deductible | $0 | $0 | ||||||
| Hospital Services for Delivery (Delivery Room, Anesthesia, Routine Nursing Care for Newborn) | ||||||||
| 20% coinsurance after deductible | $400 copayment per stay This plan will waive the hospital copayment if the member enrolls in the maternity management pre-natal program within the first 16 weeks of pregnancy, has a dental cleaning during pregnancy and satisfactorily completes the program. | 20% coinsurance after deductible | ||||||
| Outpatient Diagnostic Tests | ||||||||
| 20% coinsurance after deductible | ||||||||
| Medical Equipment, Appliances, Formulas, Prosthetics and Supplies | ||||||||
| 20% coinsurance after deductible | ||||||||
| Outpatient Prescription Drugs - Mandatory Generic | ||||||||
| Retail up to 34-day supply* (*You may purchase up to a 90-day supply at a retail pharmacy by paying multiple copayments, or the coinsurance after the deductible.) | ||||||||
| 20% coinsurance after deductible | Tier 1 - $10 copayment Tier 2 - $30 copayment Tier 3 - $45 copayment Tier 4 - $55 copayment | |||||||
| Home Delivery Services (Mail Order) (Covered Drugs up to a 90-Day Supply) | ||||||||
| 20% coinsurance after deductible | Tier 1 - $20 copayment Tier 2 - $60 copayment Tier 3 - $90 copayment Tier 4 - $110 copayment | |||||||
| Diabetic Supplies | ||||||||
| 20% coinsurance after deductible | 20% coinsurance, no deductible | |||||||
| Routine vision - Blue View Vision Network (Once Every Plan Year) | ||||||||
| Routine Eye Exam | ||||||||
| $15 copayment | $35 copayment | $40 copayment | ||||||
| Eyeglass Lenses | ||||||||
| $20 copayment | ||||||||
| Eyeglass Frames | ||||||||
| Up to $100 retail allowance (You may select a frame greater than the covered allowance and receive a 20% discount for any additional cost over the allowance.) | ||||||||
| Elective Contact Lenses (In Lieu of Eyeglass Lenses) | ||||||||
| Up to $100 retail allowance | ||||||||
| Non-Elective Contact Lenses (In Lieu of Eyeglass Lenses) | ||||||||
| Up to $250 retail allowance | ||||||||
| UV Coating, Tints, Standard Scratch-Resistant Upgrade Eyeglass Lenses (Available for Additional Cost) | ||||||||
| $15 | ||||||||
| Standard Polycarbonate Upgrade Eyeglass Lenses (Available for Additional Cost) | ||||||||
| $40 | ||||||||
| Standard Progressive Upgrade Eyeglass Lenses (Available for Additional Cost) | ||||||||
| $65 | ||||||||
| Standard Anti-Reflective Upgrade Eyeglass Lenses (Available for Additional Cost) | ||||||||
| $45 | ||||||||
| Other Add-Ons Upgrade Eyeglass Lenses (Available for Additional Cost) | ||||||||
| 20% off retail | ||||||||
| Shots - Allergy & Therapeutic Injections (At Doctor's Office, Emergency Room or Outpatient Hospital Department) | ||||||||
| 20% coinsurance after deductible | ||||||||
| Skilled Nursing Facility Stays (180-Day Per Stay Limit Per Member) | ||||||||
| Facility Services | ||||||||
| 20% coinsurance after deductible | $0 | |||||||
| Professional Provider Services | ||||||||
| 20% coinsurance after deductible | $0 | |||||||
| Spinal Manipulations and Other Manual Medical Interventions (30 Visits Per Plan Year Limit Per Member) | ||||||||
| Primary Care Physicians | ||||||||
| 20% coinsurance after deductible | $20 copayment | $25 copayment | ||||||
| Specialty Care Providers | ||||||||
| 20% coinsurance after deductible | $35 copayment | $40 copayment | ||||||
| Surgery (See Hospital Services) | ||||||||
| Therapy Services (Infusion Services, Cardiac Rehabilitation Therapy, Chemotherapy, Radiation Therapy, Respiratory Therapy, Occupational Therapy, Physical Therapy, and Speech Therapy) | ||||||||
| Facility Services | ||||||||
| 20% coinsurance after deductible | ||||||||
| Primary Care Physicians (Professional Provider Services) | ||||||||
| 20% coinsurance after deductible | ||||||||
| Specialty Care Providers (Professional Provider Services) | ||||||||
| 20% coinsurance after deductible | ||||||||
| Wellness Services | ||||||||
| Primary Care Physicians - Well Child (Office Visits at Specified Intervals Through Age 6) | ||||||||
| No copayment, coinsurance, or deductible | ||||||||
| Specialty Care Providers - Well Child (Office Visits at Specified Intervals Through Age 6) | ||||||||
| No copayment, coinsurance, or deductible | ||||||||
| Immunizations and Screening Tests - Well Child (Office Visits at Specified Intervals Through Age 6) | ||||||||
| No copayment, coinsurance, or deductible | ||||||||
| Primary Care Physicians - Routine Wellness (Age 7 & Older) - Annual Check-Up Visit (One Per Plan Year) | ||||||||
| No copayment, coinsurance, or deductible | ||||||||
| Speciality Care Providers - Routine Wellness (Age 7 & Older) - Annual Check-Up Visit (One Per Plan Year) | ||||||||
| No copayment, coinsurance, or deductible | ||||||||
| Immunization, Lab and X-Ray Services - Routine Wellness (Age 7 & Older) - Annual Check-Up Visit (One Per Plan Year) | ||||||||
| No copayment, coinsurance, or deductible | ||||||||
| Routine Screenings, Immunizations, Lab and X-Ray Services (Outside of Annual Check-Up Visit) | ||||||||
| No copayment, coinsurance, or deductible | ||||||||
| Gynecological Exam - Preventative Care (One Per Plan Year) | ||||||||
| No copayment, coinsurance, or deductible | ||||||||
| Pap Test - Preventative Care (One Per Plan Year) | ||||||||
| No copayment, coinsurance, or deductible | ||||||||
| Mammography Screening - Preventative Care (One Per Plan Year) | ||||||||
| No copayment, coinsurance, or deductible | ||||||||
| Prostate Exam (Digital Rectal Exam) - Preventative Care (One Per Plan Year) | ||||||||
| No copayment, coinsurance, or deductible | ||||||||
| Prostate Specific Antigen Test - Preventative Care (One Per Plan Year) | ||||||||
| No copayment, coinsurance, or deductible | ||||||||
| Colorectal Cancer Screenings - Preventative Care (One Per Plan Year) | ||||||||
| No copayment, coinsurance, or deductible | ||||||||
