Human Resources Blue Choice
Blue Choice
Medical Plan Schedule of Benefits | ||
In-Network | Out-of-Network | |
Annual Deductible Individual Family |
$800 $1,600 |
$1,600 $3,200 |
Coinsurance | 80% after deductible | 70% After Deductible |
Out of Pocket Maximum Individual Family |
$5,000 $11,000 |
$7,000 $13,000 |
Office Visits Primary Care Specialist Telemedicine/Virtual Visit |
$25 copay $35 copay $40 copay |
70% After Deductible |
Chiropractic Care Limited to 60 visits per year combined with Physical and Occupational Therapy |
$50 copay | Covered at 70% After Deductible |
Preventive Care | Covered at 100%; No copay | Covered at 70% After Deductible |
Outpatient Physical Therapy/ Occupational Therapy Limited to 60 visits per year combined with Muscle Manipulations |
$35 copay | Covered at 70% After Deductible |
Emergency Room True Emergency Non-Emergency Urgent Care |
Covered at 80% After Deductible Covered at 50% After Deductible $75 copay |
Covered at 80% After Deductible Covered at 50% After Deductible Covered at 70% After Deductible |
Lab and X-Ray | Covered at 100%; No copay | Covered at 70% After Deductible |
Inpatient Hospitalization | Covered at 80% After Deductible | Covered at 70% After Deductible plus $750 deductible per occurrence |
Outpatient Surgery | Covered at 80% After Deductible | Covered at 70% After Deductible |
Prescription Drugs | 30-Day Supply | 90-Day Supply (Mail Order) |
Generic Preferred Brand Non-Preferred Brand Specialty |
$20 $50 $75 $100 |
$40 $100 $150 Not Available |