Blue Cross Blue Shield BlueEdge $3,500 Health Insurance Plan

Plan Type: PPO
Coinsurance: None
Annual Deductible: Individual:$3,500 Separate
Annual Out-of-Pocket Limit: Individual:$3,000 Does not include deductible
Lifetime Maximum: $5 Million per person
Health Savings Account (HSA) Eligible: Yes
Out-of-Network Coverage: Yes
Out of Country Coverage: Yes. Paid as in-network benefits if through a WorldWide BlueCard Provider

Physicians
Primary Care Physician (PCP) Required:No
Specialist Referrals Required: No
Office Visit for Primary Doctor: No Charge after deductible
Office Visit for Specialist: No Charge after deductible

Preventive Care Coverage
Periodic Health Exam: No charge after deductible, $500 Max. Benefit
Periodic OB-GYN Exam: No charge after deductible, $500 Max. Benefit
Well Baby Care: No charge after deductible, $500 Max. Benefit

Prescription Drugs
Deductible: Medical Plan Deductible Applies
Generic: No Charge after deductible
Brand: No Charge after deductible
Non-Formulary: No Charge after deductible
Mail Order for Prescription Drugs
Generic: Member pays full discounted amount at point of sale. Benefit is subject to deductible and coinsurance
Brand: Member pays full discounted amount at point of sale. Benefit is subject to deductible and coinsurance
Non-Formulary: Member pays full discounted amount at point of sale. Benefit is subject to deductible and coinsurance
Days Supply: 90
Separate Prescription Drugs Deductible: Medical Plan Deductible Applies

Hospital Services Coverage
Emergency Room: No Charge after deductible
Outpatient Lab/X-Ray: No Charge after deductible
Outpatient Surgery: No Charge after deductible
Hospitalization: No Charge after deductible

Maternity Coverage
Pre & Postnatal Office Visit:Optional benefit
Labor & Delivery Hospital Stay: Optional benefit Additional Coverage

Chiropractic Coverage: No charge after deductible, $1 000 Max. Benefit
Mental Health Coverage: 50% Coinsurance after deductible, 30 visits per year Max. Benefit