Blue Cross Blue Shield BlueValue $2,000 Deductible

Plan Type: PPO
Annual Deductible: Individual:$2,000
Lifetime Maximum$5 Million per person
Annual Out-of-Pocket Limit: Individual:$3,000
Coinsurance: 30% coinsurance after deductible unless otherwise indicated
Out-of-Network Coverage: Yes
Out of Country Coverage: Yes. Paid as in-network benefits if through a WorldWide BlueCard Provider
Health Savings Account (HSA) Eligible: No

Physicians
Office Visit for Primary Doctor: $25 copay ($160 annual copay dollar limit) then 30% coinsurance after deductible
Office Visit for Specialist: 30% Coinsurance after deductible
Primary Care Physician (PCP) Required: No
Specialist Referrals Required: No

Prescription Drugs
Separate Prescription Drugs Deductible: Level 2, 3, 4: $500
Prescription Drugs Level 1: $15 copay
Level 2: $35 copay
Level 3: $65 copay
Level 4: $120 copay

Preventive Care Coverage
Periodic Health Exam:$25 copay or 30% coinsurance, ded. waived
Periodic OB-GYN Exam: 30% coinsurance, ded. waived Well Baby Care$25 copay or 30% coinsurance, ded. waived

Hospital Services Coverage
Emergency Room: $150 access fee, plus 30% coinsurance after deductible (access fee waived if admitted)
Outpatient Lab/X-Ray: Freestanding clinical laboratory: no charge
Freestanding radiology facility: 30% coinsurance after deductible
Outpatient Surgery: 30% Coinsurance after deductible
Hospitalization: 30% Coinsurance after deductible

Maternity Coverage
Pre & Postnatal Office Visit: Not covered except for complications of pregnancy; 30% coinsurance after deductible
Labor & Delivery: Hospital StayNot covered except for complications of pregnancy; 30% coinsurance after deductible Additional Coverage

Chiropractic Coverage: 30% Coinsurance after deductible
Mental Health Coverage: Behavioral Services Administrator: $15 copay per visit. Other providers: 50% coinsurance after deductible, 20 visits per year. $25,000 per member maximum benefit