View 2019-20 Monthly Rates
High Deductible*Key Advantage 250**Key Advantage 500**
Plan Year Deductible
In-NetworkIn-NetworkIn-Network
One PersonTwo PeopleFamilyOne PersonTwo PeopleFamilyOne PersonTwo PeopleFamily
$2,800See Family$5,600$250See Family$500$500See Family$1,000
Out-of-NetworkOut-of-NetworkOut-of-Network
One PersonTwo PeopleFamilyOne PersonTwo PeopleFamily
Deductible is combined for In-Network and Out-of-Network Services.$500See Family$1,000$1,000See Family$2,000
Plan Year Out-of-pocket Expense Limit
In-NetworkIn-NetworkIn-Network
One PersonTwo PeopleFamilyOne PersonTwo PeopleFamilyOne PersonTwo PeopleFamily
$5,000See Family$10,000$3,000See Family$6,000$4,000See Family$8,000
Out-of-NetworkOut-of-NetworkOut-of-Network
One PersonTwo PeopleFamilyOne PersonTwo PeopleFamilyOne PersonTwo PeopleFamily
$10,000See Family$20,000$5,000See Family$10,000$7,000See 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 DeductibleKey Advantage 250Key Advantage 500
Ambulance Travel
20% coinsurance after deductible
Autism Spectrum Disorder (2 years through 10 years)
20% coinsurance after deductibleCopayment/coinsurance determined by service received
Behavioral Health and EAP
Facility Services (Inpatient Treatment)
20% coinsurance after deductible$400 copayment per stay20% 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 PersonTwo PeopleFamily
$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, no deductible20% 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 deductibleCopayment/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 deductible20% coinsurance, no deductible20% 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 stay20% 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 copayment20% 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 deductible20% coinsurance, no deductible20% coinsurance after deductible
LiveHealth Online
Determined by services received$20$25
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 deductible20% coinsurance, no deductible20% 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 deductibleTier 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 deductibleTier 1 - $20 copayment
Tier 2 - $60 copayment
Tier 3 - $90 copayment
Tier 4 - $110 copayment
Diabetic Supplies
20% coinsurance after deductible20% 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 deductible20% coinsurance, no deductible20% 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
View 2019-20 Monthly Rates