Blue Value Select PPO Plan
1500
Lifetime Maximum
| In-Network | $5,000,000 |
| Out-of-Network | $5,000,000 |
Annual Deductible
| In-Network | $1,500 |
| Out-of-Network | $3,000 |
Coinsurance
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Annual Out-of-Pocket Limit
| In-Network | $2,000 |
| Out-of-Network | No Out-of-Pocket Maximum |
Office Visits
| In-Network | $30 office visit copayment |
| Out-of-Network | Plan pays 60% |
Preventive care through age
5
| In-Network | $30 office visit copayment |
| Out-of-Network | Plan pays 60% of covered charges |
Preventive care for adults
| In-Network | $30 office visit copayment |
| Out-of-Network | Plan pays 60% of covered charges |
Lab/X-ray
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Hospital-Based Physicians
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Maternity * Family Contracts
Only
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Outpatient Facility
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Physical/Occupational Therapy/Chiropractic
Therapy
| In-Network | Plan pays 80%, 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 80% |
| 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 80% 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 |