The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.
|Maximum Out Of Pocket (single/family)|
Maximum Out Of Pocket (single/family)
The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.
|Primary Care Physician Services|
Primary Care Physician Services
A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.
|Maternity Care (prenatal and postnatal)|
Maternity Care (prenatal and postnatal)
Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
|Inpatient Hospital Services|
Inpatient Hospital Services
Treatment at a hospital that requires the individual to stay there.
|Outpatient Hospital Services|
Outpatient Hospital Services
Treatment at a hospital that does not require the individual to stay there.
Emergency services you get in an emergency room.
$300, then deductible, then 50%
Emergency medical transportation.
|Freestanding Ambulatory Surgical Center|
Freestanding Ambulatory Surgical Center
A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.
|Mental Health and Substance Abuse|
Mental Health and Substance Abuse
Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.
Covered as any other medical benefit.
|Gynecologist Exam (one per benefit year)|
Gynecologist Exam (one per benefit year)
Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.
|Routine Screening Mammogram|
Routine Screening Mammogram
A radiological examination of the breast for purposes of detecting breast cancer.
|Routine Screening Colonoscopy|
Routine Screening Colonoscopy
An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.
Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes.
Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you.
Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket.
Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs.
Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs.
Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.
Tier 0: $0 retail/$0 mail order;
Tier 1: deductible, then 50% retail/deductible, then 50% mail order;
Tier 2: deductible, then 50% retail/deductible, then 50% mail order;
Tier 3: deductible, then 50% retail/deductible, then 50% mail order;
Tier 4: deductible, then 50% retail/deductible, then 50% mail order
Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs.
Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive.
Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.
Tier 5: deductible, then 50% retail/deductible, then 50% mail order;
Tier 6: deductible, then 50% retail/deductible, then 50% mail order
|Durable Medical Equipment|
Durable Medical Equipment
Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
|Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation|
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation
Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.
Deductible, then 50%; 30 combined visits per benefit year.
Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.
A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.