HMO Blue Premier Value with Coinsurance

Details at a Glance

• Plan Type
• HMO
• Office Visit for Primary Doctor
• $25 per visit
• Office Visit for Specialist
• $40 per visit
• Coinsurance
• 35% coinsurance
• Annual Deductible
• Individual:$1,000
• Separate Prescription Drugs Deductible
• None
• Prescription Drugs
• Generic: $15 Copay
• Brand: $30 Copay
• Non-Formulary: $50 Copay;
  Applies to non-preferred drugs and non-formulary drugs approved through a formulary exception
• Annual Out-of-Pocket Limit
• Individual:$2,000
  Includes deductible
  copayments over $100 and coinsurance;
  does not include prescription drug benefits
• Lifetime Maximum
• N/A
• Health Savings Account (HSA) Eligible
• No
• Out-of-Network Coverage
• No 
• Out of Country Coverage
• Emergency Care Only

Physicians

• Primary Care Physician (PCP) Required
• Yes
• Specialist Referrals Required
• Yes

Preventive Care Coverage

• Periodic Health Exam
• $15 per visit (no cost for related routine lab tests, x-rays and immunizations)
• Periodic OB-GYN Exam
• $15 per visit (no cost for related routine lab tests)
• Well Baby Care
• $15 per visit (no cost for related routine lab tests, x-rays and immunizations)

Prescription Drug Coverage

• Generic Prescription Drugs
• $15 Copay
• Brand Prescription Drugs
• $30 Copay
• Non-Formulary Prescription Drugs Coverage
• $50 Copay;
  Applies to non-preferred drugs and non-formulary drugs approved through a formulary exception
• Mail Order for Prescription Drugs
• Generic: $30 Copay
• Brand: $60 Copay
• Non-Formulary: $150 Copay;
  Applies to non-preferred drugs and non-formulary drugs approved through a formulary exception
• Days Supply: 90
• Separate Prescription Drugs Deductible
• None

Hospital Services Coverage

• Emergency Room
• $150 per visit, waived if admitted or for observation stay
• Outpatient Lab/X-Ray
• 35% coinsurance
• Outpatient Surgery
• $25 per visit for office setting when performed by your designated PCP or network OB-Gyn physician, $40 when performed by other network providers.
  35% Coinsurance per admission for ambulatory surgical facility, hospital outpatient department or surgical day care unit.
• Hospitalization
• No cost after deductible (applies to inpatient services in a general hospital)

Maternity Coverage

• Pre & Postnatal Office Visit
• Coverage Provided.
  See Summary of Benefits for details
• Labor & Delivery Hospital Stay
• Coverage Provided.
  See Summary of Benefits for details

Additional Coverage

• Chiropractic Coverage
• $40 per visit (35% Coinsurance for lab tests and x-rays)
• Mental Health Coverage
• Inpatient: No cost.
  Outpatient: $25 per visit

Additional Information

• A.M. Best Rating
• NR-5 as of 05/14/2012
• Electronic Signature for Application Available
• Yes
• Will insurance company obtain and pay for medical records?
• No
• Additional information about this health insurance plan is available in the documents below.
  Plan Brochure
  Exclusions and Limitations
  Summary of Benefits & Coverage (Not available)
  The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Action

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