You can reduce your deductible(s) by completingĬall to Health, a well-being initiative that focuses on the four dimensions of wholeness: spiritual, health, financial, and vocational.Ī copay is a flat dollar amount that you pay upfront for certain services when using network providers.If you enroll any family members, you are responsible for two medical deductibles, one for yourself and one for all your family members combined.PPO Deductibles and Medical Out-of-Pocket Maximums chart. PPO deductibles are based on a percentage of your effective salary, as shown on the.The deductible is a specified annual dollar amount you must pay for covered medical services before the plan begins to pay benefits. All benefits are subject to the definitions, limitations, and exclusions set forth in the federal brochure.To better understand the coverage provided under the PPO, it’s important to know these key terms. Before making a final decision, please read the Plan’s federal brochure (RI 71-005). This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. The formulary and/or pharmacy network may change at any time. Enrollment in MPDP depends on contract renewal. The FEP Medicare Prescription Drug Program is a prescription drug plan with a Medicare contract. Your MPDP pharmacy out-of-pocket maximum is part of it, not added to it. ^ What you’ll pay for a 30-day supply of covered drugs.ġ If you have Medicare Part B primary, your costs for prescription drugs may be lower.Ģ On limited occasions, such as for certain drugs that require prior approval, you will need to file a claim for services received from Preferred providers.ģ You must be the contract holder or spouse, 18 or older, on a Standard or Basic Option Plan to earn incentive rewards.Ĥ Eligible expenses for the services of Preferred (In-Network) providers also count toward these limits.ĥ You still have an overall medical out-of-pocket maximum. † Subject to the calendar year deductible: $350 per person or $700 in total for Self + One or Self & Family contracts. Certain out-of-pocket costs do not apply if Medicare is your primary coverage for medical services (it pays first). * If you use a Non-preferred provider under Standard Option, you generally pay any difference between our allowance and the billed amount, in addition to any share of our allowance shown in the table above. 3Ĭost sharing may not apply or may be different if Medicare is your primary coverage (it pays first) $25 copay per treatment up to 12 visits per yearģ5% of our allowance † up to 12 visits per yearĮarn up to $120 for completing three eligible Online Health Coach goals. 3Įarn up to $120 for completing three eligible Daily Habits goals. The difference between the fee schedule amount and the Maximum Allowable Charge (MAC)Įarn $50 for completing the Blue Health Assessment. $30 copay per treatment up to 12 visits a yearģ5% of our allowance † up to 12 visits a year Inpatient (Precertification is required) : $450 per admission copay, plus 35% of our allowanceĭiagnostic services (such as sleep studies, X-rays, CT scans) Inpatient (Precertification is required) : $350 per admission Outpatient facility care: 35% of our allowance † Inpatient hospital: $450 per admission copay for unlimited days, plus 35% of our allowance Pre-/postnatal professional care: 35% of our allowance † Tier 5 (Non-preferred specialty): $85 copay Tier 5 (Non-preferred specialty): 30% of our allowance ^ Tier 4 (Preferred specialty): 30% of our allowance ^ Tier 3 (Non-preferred brand): 50% of our allowance Tier 2 (Preferred brand): 30% of our allowance Medical Emergency: 35% our our allowance † $0 for first 2 visits and all nutrition visits Nothing for covered preventive screenings, immunizations and services
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