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Together Blue EPO Gold 1700 HSA
Plan Summary
Plan Type EPO
Office Visit for Primary Doctor
Find Doctors 		$20 Copay after deductible
Office Visit for Specialist $20 Copay after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) $20 Copay after deductible
Annual Deductible Individual: $1,700
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 20%
Retail Prescription Drugs Generic Drugs: $0 Copay after deductible;
Preferred Brand Drugs: $30 Copay after deductible;
Non-Preferred Brand Drugs: $150 Copay after deductible;
Specialty Drugs: 50% Coinsurance after deductible;
Annual Out-of-Pocket Limit Individual: $5,700
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Emergency Care Only 
Out-of-Country Coverage Yes. Coverage is provided through the Blue Cross Blue Shield Global Core when a Member requires Emergency Care Services or Urgent Care Services while traveling or living outside the United States. All Emergency Care Services and Urgent Care Services are covered in accordance within the Member's Agreement. 
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room $175 Copay after deductible
Emergency Ambulance Services 20% Coinsurance after deductible
Urgent Care Facility $40 Copay after deductible
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $0 Copay after deductible;
Preferred Brand Drugs: $30 Copay after deductible;
Non-Preferred Brand Drugs: $150 Copay after deductible;
Specialty Drugs: 50% Coinsurance after deductible;
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Outpatient Surgery Physician/Surgical Services:
$130 Copay after deductible
Outpatient Facility Fee:
$130 Copay after deductible
Outpatient Lab/X-Ray Outpatient Lab:
$20 Copay after deductible
X-rays:
$20 Copay after deductible
Imaging (CT and PET scans, MRIs) $175 Copay after deductible
Outpatient Mental Health $20 Copay after deductible
Outpatient Substance Abuse $20 Copay after deductible
Outpatient Rehabilitation Services (PT, OT, ST) $20 Copay after deductible
Inpatient Coverage
Hospitalization Inpatient Hospital Services:
$450 Copay per Stay after deductible
Inpatient Physician and Surgical Services:
No Charge after deductible
Skilled Nursing Facility $450 Copay per Stay after deductible, limited to 120 Days per Benefit Period
Inpatient Mental Health $450 Copay per Stay after deductible
Inpatient Substance Abuse $450 Copay per Stay after deductible
Home Healthcare 20% Coinsurance after deductible, limited to 60 Visit(s) per Benefit Period
Maternity Coverage
Pre & Postnatal Office Visit No Charge after deductible
Labor & Delivery Hospital Stay $450 Copay after deductible
Pediatric Services
Dental Checkup for Children No Charge, limited to 1 Exam(s) per 6 Months
Vision Screening for Children No Charge, limited to 1 Exam(s) per Year
Eye Glasses for Children No Charge after deductible, limited to 1 Item(s) per Year
Major Dental Coverage (Pediatric) 20% Coinsurance after deductible
Additional Coverage
Chiropractic Coverage $20 Copay after deductible, limited to 20 Visit(s) per Benefit Period
Durable Medical Equipment 20% Coinsurance after deductible
Hospice 20% Coinsurance after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) No Charge, limited to 1 Exam(s) per Year
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating A as of 11/20/2024
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • 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.