Blue Value PPO Plan 10000

Lifetime Maximum

In-Network $5,000,000
Out-of-Network $5,000,000

Annual Deductible

In-Network $10,000
Out-of-Network $20,000

Coinsurance

In-Network Plan pays 70%
Out-of-Network Plan pays 60%


Annual Out-of-Pocket Limit

In-Network $5,000
Out-of-Network No Out-of-Pocket Maximum


Office Visits

In-Network $40 copayment for first 6 visits; after 6 visits, Plan pays 70%
Out-of-Network Plan pays 60%


Preventive care through age 5

In-Network Plan pays 70%
Out-of-Network Plan pays 70%


Preventive care for adults

In-Network Plan pays 70% of covered charges
Out-of-Network Plan pays 60% of covered charges


Lab/X-ray

In-Network Plan pays 70%
Out-of-Network Plan pays 60%


Hospital-Based Physicians

In-Network Plan pays 70%
Out-of-Network Plan pays 60%


Maternity * Family Contracts Only

In-Network Not Covered
Out-of-Network Not Covered


Outpatient Facility

In-Network Plan pays 70%
Out-of-Network Plan pays 60%


Physical/Occupational Therapy/Chiropractic Therapy

In-Network Plan pays 70%, 30 visits per year*
Out-of-Network Plan pays 60% 30 visits per year*
* In- and out-of-network visits combined

Behavioral Health/Substance Abuse

In-Network $100 per day up to $3,000 per year; $10,000 lifetime maximum
Out-of-Network Not Covered


Inpatient Hospital

In-Network Plan pays 70%
Out-of-Network Plan pays 60%


Emergency Services

a In-Network Out-of-Network
Life threatening medical emergency or serious accidental injury $150 ER copayment (waived if admitted) $150 ER copayment (waived if admitted)
Non-accidental injury or non-medical emergency $150 ER copayment; Plan pays 70% of covered charges after copayment $150 ER copayment; Plan pays 60% of covered charges after copayment


Prescription Drug

Generic/Formulary $15 copayment
Brand/Formulary $30 copayment
Non-Formulary $45 copayment

* No maternity benefits are payable for the first twelve (12) months of coverage.

Please note: Unless otherwise stated, all benefits are subject to the deductible.