Human Resources Blue Preferred
Blue Preferred
Medical Plan Schedule of Benefits | ||
In-Network | Out-of-Network | |
Annual Deductible
Individual |
$500 $1,000 |
$1,000 $2,000 |
Coinsurance | 80% after deductible | 60% After Deductible |
Out of Pocket Maximum
Individual |
$4,000 $9,000 |
$6,000 $13,000 |
Office Visits
Primary Care |
$25 copay $35 copay $25 copay |
60% After Deductible |
Chiropractic Care
Limited to 60 visits per year combined with Physical and Occupational Therapy |
$35 copay | Covered at 60% After Deductible |
Preventive Care | Covered at 100%; No copay | Covered at 60% After Deductible |
Outpatient Physical Therapy/
Occupational Therapy Limited to 60 visits per year combined with Muscle Manipulations |
$35 copay | Covered at 60% 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 60% After Deductible |
Lab and X-Ray | Covered at 100%; No copay | Covered at 60% After Deductible |
Inpatient Hospitalization | Covered at 80% After Deductible | Covered at 60% After Deductible plus $750 deductible per occurrence |
Outpatient Surgery | Covered at 80% After Deductible | Covered at 60% 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 |