March 18, 2010

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Blue Cross Blue Shield of Louisiana – BLUE MAX PPO – LOUISIANA

A comparison of the BLUE MAX PPO offered by Blue Cross Blue Shield of Louisiana is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application BLUE MAX PPO Application BLUE MAX PPO Application
Brochure BLUE MAX PPO Brochure BLUE MAX PPO Brochure
Copay N/A N/A
Office Visit Subject to deductible and coinsurance. Subject to deductible and coinsurance.
Deductible $5,000 Individual, $15,000 Family $5,000 Individual, $15,000 Family
Coinsurance 70% 50%
Coinsurance Limit Out-of-Pocket Maximum- $2,000 per calendar year Out-of-Pocket Maximum- $2,000 per calendar year
Out-of-Pocket Maximum $2,000 per calendar year $2,000 per calendar year
Lifetime Maximum $5 million for each covered member $5 million for each covered member
Prescription Drugs
  • Separate $1,000 prescription drug deductible applies (member must meet the prescription deductible before any prescription drug benefits are payable)
  • Generic drugs (and certain brand-name drugs)- $4
  • Brand-name drugs (and certain generic drugs)- $25
  • Generic or brand-name drugs with a therapeutic alternative- $45
  • Multi-Source Brand drugs- $60
  • Injectables- $50.
  • For retail pharmacies, the copayment covers up to a 30-day supply.
  • Mail-order services are also available. When ordering drugs by mail, you pay three copayments and receive up to a 90-day supply. A separate copayment is required for each dispensing you receive
    		•
  • Separate $1,000 prescription drug deductible applies (member must meet the prescription deductible before any prescription drug benefits are payable)
  • Generic drugs (and certain brand-name drugs)- $4
  • Brand-name drugs (and certain generic drugs)- $25
  • Generic or brand-name drugs with a therapeutic alternative- $45
  • Multi-Source Brand drugs- $60
  • Injectables- $50.
  • For retail pharmacies, the copayment covers up to a 30-day supply.
  • Mail-order services are also available. When ordering drugs by mail, you pay three copayments and receive up to a 90-day supply. A separate copayment is required for each dispensing you receive
    		•
    Emergency Room Subject to deductible and coinsurance. Subject to deductible and coinsurance.
    Adult Preventative Care Covered 100%- One routine Pap smear per calendar year, One routine physical per benefit period, One mammography exam per benefit period, One routine colon (hemoccult) test per calendar year, One routine gynecological exam per calendar year, and One prostate (PSA) screening test and one digital rectal exam per calendar year for members age 50 and older, or more frequently if recommended by physician. Subject to deductible and coinsurance.
    Child Preventative Care Covered 100%- Routine pediatric exams and all immunizations. Subject to deductible and coinsurance.
    Lab / X-Ray Subject to deductible and coinsurance. Subject to deductible and coinsurance.
    Maternity Optional Benefit not availableOptional Benefit- Subject to deductible and coinsurance Optional Benefit not availableOptional Benefit- Subject to deductible and coinsurance
    Physical Therapy
  • Subject to deductible and coinsurance.
  • Limited to $4,500 combined maximum each Benefit Period.
    		•
  • Subject to deductible and coinsurance.
  • Limited to $4,500 combined maximum each Benefit Period.
    		•
    Skilled Nursing BLUE MAX PPO BLUE MAX PPO
    Home Health Care BLUE MAX PPO BLUE MAX PPO
    Mental Health Not covered Not covered
    Hospital Care Subject to deductible and coinsurance. Subject to deductible and coinsurance.
    Optional Benefits BLUE MAX PPO BLUE MAX PPO