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BLUECHOICE HEALTHCARE PLAN (HMO) |
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CHOICE OF PROVIDER |
BlueChoice Healthcare Plan Hospitals & Doctors |
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Annual Deductible |
No deductible |
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Annual Out-of-Pocket Maximum (excluding co-payments) |
$1,000 Employee |
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Lifetime Maximum |
Unlimited |
OFFICE SERVICES |
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Primary Care Physician (PCP) Office Visit |
You pay a $15.00 co-payment per visit |
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Specialty Care Physician (SCP) Office Visit |
You pay a $25.00 co-payment per visit |
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Annual Gynecological Exam by PCP |
You pay a $20.00 co-payment per visit |
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Annual Gynecological Exam by SCP |
You pay a $25.00 co-payment per visit |
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Maternity Services (Physician Care per Pregnancy |
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Mammograms |
Included in office visit co-payment |
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Pap Smear |
Included in office visit co-payment |
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Prostate Screening |
Included in office visit co-payment |
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Periodic Health Assessment |
You pay a $20 co-payment per visit |
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Flu Shots |
Included in office visit co-payment |
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Well Baby Care |
You pay a $20 co-payment per visit |
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Immunizations |
Included in office visit co-payment |
INPATIENT SERVICES/OUTPATIENT SERVICES |
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Semi-Private Room, Board and Other Covered Services |
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Maternity and Newborn Care |
Plan Pays 90% |
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Doctor Visits |
Plan Pays 100% |
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EMERGENCY SERVICES (EMERGENCY ROOM) |
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Medical emergencies are paid at 100% after emergency room co-payment. No benefits for non-emergency visit to the emergency room. |
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OTHER SERVICES |
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Prescription Drugs |
You pay a $20 co-payment for generic, $30.00 for brand name and $50.00 for non-formulary per prescription for a 30 day supply. |
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Mail Order
Prescription Drugs |
You pay a $40 co-payment for generic, $60.00 for brand name and $100.00 for non-formulary per prescription for a 90 day supply from PrecisionRX |
MENTAL HEALTH/SUBSTANCE ABUSE |
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Inpatient – 30 days per year |
Plan Pays 90% |
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Outpatient – 5- visits per year |
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NON-COVERED SERVICES
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Chiropractic Services |
Not Covered |
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This outline is designed only to provide a
summary of benefits. |
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