| Network |
See Provider |
See Provider |
| Application |
Essential Blue Plus Application |
Essential Blue Plus Application |
| Brochure |
Essential Blue Plus Brochure |
Essential Blue Plus Brochure |
| Copay |
$30 |
N/A |
| Office Visit |
Physician Office Visits (You pay deductible and/or coinsurance for other services during a physician office visit): $30 copayment for specifically listed services (Physician office visits and preventive care services are limited to a combined total of 10 office visits per person, per benefit period) |
Physician Office Visits (You pay deductible and/or coinsurance for other services during a physician office visit): 50% of allowed amount for covered services after meeting your deductible (Physician office visits and preventive care services are limited to a combined total of 10 office visits per person, per benefit period) |
| Deductible |
Individual: $2,000, Family: $4,000 |
Individual: $2,000, Family: $4,000 |
| Coinsurance |
80% |
50% |
| Coinsurance Limit |
Essential Blue Plus |
Essential Blue Plus |
| Out-of-Pocket Maximum |
$4,000 per person (Includes your deductible but does not include $5,000 pregnancy deductible) |
$4,000 per person (Includes your deductible but does not include $5,000 pregnancy deductible) |
| Lifetime Maximum |
$1,000,000 lifetime benefit limit per person |
$1,000,000 lifetime benefit limit per person |
| Prescription Drugs |
Prescription Drugs (Brand name and generic drugs): 50% coinsurance, no deductible required - Prescription drug benefit limited to a maximum of $1,200 per person, per benefit period - 90-day supply limit |
Prescription Drugs (Brand name and generic drugs): 50% coinsurance, no deductible required - Prescription drug benefit limited to a maximum of $1,200 per person, per benefit period - 90-day supply limit |
| Emergency Room |
Emergency Room Facility Services: $100 copayment, after which 80% of the allowed amount for covered services after meeting your deductible Emergency Room Physician Services: 80% of the allowed amount for covered services after meeting your deductible Ambulance Transportation Services (Limited to $500 per person, per benefit period): 80% of the allowed amount for covered services after meeting your deductible |
Emergency Room Facility Services: $100 copayment, after which 50% of the allowed amount for covered services after meeting your deductible Emergency Room Physician Services: 50% of the allowed amount for covered services after meeting your deductible Ambulance Transportation Services (Limited to $500 per person, per benefit period): 50% of the allowed amount for covered services after meeting your deductible |
| Adult Preventative Care |
Preventive Care Services: You pay nothing for services specifically listed up to $500 - for services in excess of $500 you pay your deductible and coinsurance (Physician office visits and preventive care services are limited to a combined total of 10 office visits per person, per benefit period) Immunizations: You pay nothing for specifically listed immunizations Diagnostic Mammogram Services: 80% of the allowed amount for covered services after meeting your deductible |
Preventive Care Services: 50% of the allowed amount after meeting your deductible (Physician office visits and preventive care services are limited to a combined total of 10 office visits per person, per benefit period) Immunizations: You pay nothing for specifically listed immunizations |
| Child Preventative Care |
Preventive Care Services: You pay nothing for services specifically listed up to $500 - for services in excess of $500 you pay your deductible and coinsurance (Physician office visits and preventive care services are limited to a combined total of 10 office visits per person, per benefit period) Immunizations: You pay nothing for specifically listed immunizations |
Preventive Care Services: 50% of the allowed amount after meeting your deductible (Physician office visits and preventive care services are limited to a combined total of 10 office visits per person, per benefit period) Immunizations: You pay nothing for specifically listed immunizations |
| Lab / X-Ray |
Inpatient Diagnostic Laboratory and X-ray Services (From contracting providers only): 80% of the allowed amount for covered services after meeting your deductible Outpatient Diagnostic Laboratory and X-ray Services (Limited to a combined total of $2,000 per person, per benefit period): 80% of the allowed amount for covered services after meeting your deductible |
Inpatient Diagnostic Laboratory and X-ray Services (From contracting providers only): 50% of the allowed amount for covered services after meeting your deductible Outpatient Diagnostic Laboratory and X-ray Services (Limited to a combined total of $2,000 per person, per benefit period): 50% of the allowed amount for covered services after meeting your deductible |
| Maternity |
Pregnancy Services (A separate $5,000 deductible applies, except in cases of complications): 80% after meeting a separate $5,000 deductible |
Pregnancy Services (A separate $5,000 deductible applies, except in cases of complications): 50% after meeting a separate $5,000 deductible |
| Physical Therapy |
Inpatient Physical Rehabilitation (From contracting providers only): 80% of the allowed amount for covered services after meeting your deductible Selected Therapy Services (Radiation, chemotherapy and renal dialysis): 80% of the allowed amount for covered services after meeting your deductible Chiropractic Services: Not covered Outpatient Occupational Therapy, Outpatient Physical Therapy, & Outpatient Speech Therapy: Not covered Growth Hormone Therapy & Home Intravenous Therapy: Not covered |
Inpatient Physical Rehabilitation (From contracting providers only): Not covered Selected Therapy Services (Radiation, chemotherapy and renal dialysis): 50% of the allowed amount for covered services after meeting your deductible Chiropractic Services: Not covered Outpatient Occupational Therapy, Outpatient Physical Therapy, & Outpatient Speech Therapy: Not covered Growth Hormone Therapy & Home Intravenous Therapy: Not covered |
| Skilled Nursing |
80% of the allowed amount for covered services after meeting your deductible (Limited to 30-days per person, per benefit period) |
50% of the allowed amount for covered services after meeting your deductible (Limited to 30-days per person, per benefit period) |
| Home Health Care |
Home Health Care: Not covered Hospice Services (Lifetime benefit limit of $10,000 per person, no deductible required): 80% of the allowed amount of covered services are meeting your deductible |
Home Health Care: Not covered Hospice Services (Lifetime benefit limit of $10,000 per person, no deductible required): Not covered |
| Mental Health |
Psychiatric Inpatient Services: Not covered Psychiatric Outpatient Services: Not covered |
Psychiatric Inpatient Services: Not covered Psychiatric Outpatient Services: Not covered |
| Hospital Care |
Inpatient Physician, Surgical and Medical Professional Services: 80% of the allowed amount for covered services after meeting your deductible Hospital Services (Inpatient care, outpatient surgery and pre-admission testing): 80% of the allowed amount for covered services after meeting your deductible |
Inpatient Physician, Surgical and Medical Professional Services: 80% of the allowed amount for covered services after meeting your deductible Hospital Services (Inpatient care, outpatient surgery and pre-admission testing): 50% of the allowed amount for covered services after meeting your deductible |
| Optional Benefits |
Essential Blue Plus |
Essential Blue Plus |
