| Company/Plan Name |
 Personal BluePlan 3 |
| Deductible |
|
| In-Network |
$500 Per Member, Per Benefit Period |
| Out-Network |
$500 Per Member, Per Benefit Period |
| Maximum Family Deductible |
No family maximum applies. |
| Coinsurance |
|
| In-Network |
90/10 to $50,000 |
| Out-Network |
70/30 to $26,668 |
| Maximum Out-Of-Pocket Coinsurance |
|
| In-Network |
$5,000 |
| Out-Network |
$8,000 |
| Maximum Benefit |
$2,000,000 lifetime maximum |
| Physician Office Visit |
|
| In-Network |
Doctor's visits are not covered. Physician visits are covered on an inpatient and outpatient hospital basis only. Subject to Deductible & Coinsurance. |
| Out-Network |
Doctor's visits are not covered.
|
| Outpatient Lab & X-Ray |
|
| In-Network |
Subject to Deductible & Coinsurance. Only covered if admitted within 14 days of the service & if the admission is for a related cause. |
| Out-Network |
Subject to Deductible & Coinsurance. Only covered if admitted within 14 days of the service & if the admission is for a related cause. |
| Outpatient Preventive Care |
Limited Benefit |
| In-Network |
Mammograms are subject to Deductible & Coinsurance at mammogram network provider. OB/GYN Exam, Pap smears & Prostate cancer screenings are not covered. |
| Out-Network |
Not Covered |
| Prescription Drugs |
|
| Generic |
Not Covered |
| Brand Name(formulary) |
Not Covered |
| Brand Name(Non-formulary) |
Not Covered |
| Outpatient Surgery |
|
| In-Network |
Subject to Deductible & Coinsurance |
| Out-Network |
Subject to Deductible & Coinsurance |
| Emergency Room |
|
| In-Network |
Subject to Deductible & Coinsurance |
| Out-Network |
Subject to Deductible & Coinsurance |
| Maternity Prenatal/Post Natal |
|
| In-Network |
Not Available |
| Out-Network |
Not Available |
| Inpatient Benefits |
|
| Hospitalization |
|
| In-Network |
Subject to Deductible & Coinsurance |
| Out-Network |
$250 CoPay, then subject to Deductible & Coinsurance. |
| Surgical |
|
| In-Network |
Subject to Deductible & Coinsurance |
| Out-Network |
$250 CoPay, then subject to Deductible & Coinsurance. |
| Maternity |
|
| In-Network |
Not Available |
| Out-Network |
Not Available |
| Rate Guarantee |
None |
| Optional Benefits |
|
| Supplemental Accident |
Optional Accident Medical Expense Coverage available (not quoted) |
| 24 Hour Coverage |
Included in plan (not an optional benefit). Injuries or diseases not paid by worker?s compensation will be considered. |
| Other |
Not Available |