Blue Cross Blue Shield Health Check Basic $1000 Health Insurance Plan

Plan Type: PPO
Health Savings Account (HSA) Eligible: No
Coinsurance: 20% after deductible

Physicians
Office Visit for Primary Doctor: $35 Copay
Office Visit for Specialist: $35 Copay
Primary Care Physician (PCP) Required: No
Specialist Referrals Required: No

Prescription Drugs
Generic: 50% Coinsurance, not subject to deductible
Brand: 50% Coinsurance, not subject to deductible
Non-Formulary: 50% Coinsurance, not subject to deductible
Separate Prescription Drugs Deductible: A separate $20,000 stop-loss applies for prescription drug coverage

Out-of-Network Coverage: Yes
Out of Country Coverage: Yes. Paid as in-network benefits if through a WorldWide BlueCard Provider

Preventive Care Coverage
Periodic Health Exam: Not Covered
Periodic OB-GYN Exam: $35 Copay
Well Baby Care: $35 Copay

Hospital Services Coverage
Emergency Room: $100 per visit deductible (waived if admitted), plus 20% Coinsurance after deductible
Outpatient Lab/X-Ray: 20% Coinsurance after deductible
Outpatient Surgery: $200 per visit deductible, plus 20% Coinsurance after deductible
Hospitalization $500 per visit deductible, plus 20% Coinsurance after deductible

Maternity Coverage
Pre & Postnatal Office Visit: Optional benefit. Subject to the 365 day waiting period.
Labor & Delivery Hospital Stay: Optional benefit. Subject to the 365 day waiting period.

Additional Coverage
Chiropractic Coverage: 20% Coinsurance after deductible. 25 visits per year
Mental Health Coverage: 50% Coinsurance after deductible. $1,000 outpatient annual max. benefit. Severe mental illness covered as any other illness.