BlueChoice Options - Individual and Families - Looking for Insurance?

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Individuals and Families: BlueChoice Options

Other Health Plans:

BlueChoice

The chart below reflects in-network benefits only.

STEP 1: Choose your deductible Choose the amount that works best for you.	$500	$1,000	$2,500	$5,000	$10,000	$25,000
	After you meet the deductible, then you begin paying the 20% coinsurance, if applicable.

STEP 2: Choose your coinsurance or copayments Depending upon the deductible amount you select, you have a choice of coinsurance or copayment options.	CHOOSE: 20% coinsurance up to a $1,000 out-of-pocket coinsurance maximum	CHOOSE: 20% coinsurance up to a $1,000 out-of-pocket coinsurance maximum	CHOOSE: no coinsurance	CHOOSE: $30 primary care physician visits copay/$50 specialist visits copay*	CHOOSE: $30 primary care physician visits copay/$50 specialist visits copay*	CHOOSE: $30 primary care physician visits copay/$50 specialist visits copay*
	OR 20% coinsurance up to a $2,000 out-of-pocket coinsurance maximum	OR 20% coinsurance up to a $2,000 out-of-pocket coinsurance maximum	OR 20% coinsurance up to a $2,000 out-of-pocket coinsurance maximum	OR Physician services subject to deductible	OR Physician services subject to deductible	OR Physician services subject to deductible
	- YOUR SELECTED DEDUCTIBLE OPTION ALSO INCLUDES -
	$30 primary care physician visits copay/$50 specialist visits copay*	$30 primary care physician visits copay/$50 specialist visits copay*	$30 primary care physician visits copay/$50 specialist visits copay*	No coinsurance	No coinsurance	No coinsurance

Once you meet the annual out-of-pocket coinsurance maximum — if applicable —
BlueChoice pays 100% of covered services for the remainder of the calendar year.

STEP 3:
Choose the prescription drug plan that best meets your needs

Complete Care: Our standard drug list (formulary) includes both brand and generic drugs. This plan uses our standard drug list (formulary), which includes both brand-name and generic drugs. You are responsible for a $10 copayment for generic drugs, $30 copayment for preferred brands and a $50 copayment for non-preferred brands.

Essential Care: Our Essential Care drug list (formulary) is generic-based, with a very limited number of brand-name drugs. You are responsible for a $10 copayment for generic drugs and a $50 copayment for the limited number of brand-name drugs.

STEP 4:
If you wish, you may add maternity services

Add the maternity rider - Dependents other than a covered spouse cannot purchase the maternity rider.

$5,000 paid per pregnancy, after a 12-month waiting period. No deductible. Applicable coinsurance applies. Does not apply to your out-of-pocket coinsurance maximum.

NOTE: The primary care physician/specialist copayment covers services performed in the office at 100%.

*The following services are covered under the primary care physician's copay when performed in an in-network general practitioner, pediatrician, family practitioner or internal medicine doctor's office and billed by that physician:

Office Visit
Diagnostic X-Ray
Lab Work
Accident or Emergency Medical Care

Surgery
Allergy Shots
Injections

**The following services are covered under the specialist copay when performed by an in-network specialist who performs a face-to-face exam or consult and bills all services on the same claim:

Office Visit Lab work Commonly Administered Injections	Allergy Testing Plain Film X-Ray
All other services that are covered by the medical plan and performed by in-network doctors in the office will be subject to the deductible and coinsurance. All services performed by out-of-network providers are subject to the out-of-network deductible and coinsurance.

BlueChoice features an "open access" network. There are no referrals required.