Blue Care Elect Deductible Plan Benefits At-A-Glance
Plan Specifics You Pay (In-Network Costs)
Plan-year deductible $250 for one member, $500 for two members, or $750 for a family
Plan-year out-of-pocket maximum $2,500 for an individual or $5,000 for a family for in-network and out-of-network services combined
Benefit You Pay (In-Network Costs)
Preventive care, routine physicals, GYN, well child, routine hearing and vision exams, family planning Nothing
Office visits (sick care/ non-preventive) $20 per visit, no deductible
Emergency room $100 per visit (copayment waived if admitted or for an observation stay)
Inpatient hospital care $300 per admission after deductible
Outpatient surgery  

Office or health center

$20 per visit1

Ambulatory surgical facility, hospital, or surgical day care unit

$150 per admission after deductible
CT scans, MRIs, and other imaging tests $100 per category per date of service after deductible

 

1. The copayment is waived for restorative dental service and orthodontic treatment or prosthetic management therapy for members under age 18 to treat cleft lip and cleft palate.

Summary of Benefits Summary of Benefits
Subscriber Certificate Summary of Benefits + Coverage
Dependent Benefits

This plan covers dependents up to the age of 26, even if they aren't considered dependents on a tax return, don't attend school, and regardless of whether or not they have a job—unless they are eligible for coverage under a non-parent, employer-sponsored plan.

Prescription Drug Coverage

Your plan includes prescription drug coverage. Covered medications are separated into three tiers, and the amount you pay depends on the medication's tier.

Prescription Drug Benefits You Pay (In-Network Costs)1
Retail pharmacies (up to a 30-day supply) $10 for Tier 12
$25 for Tier 2
$50 for Tier 3
Mail service pharmacy (up to a 90-day supply) $20 for Tier 12
$50 for Tier 2
$110 for Tier 3

 

1. Cost share waived for certain orally administered anticancer drugs

2. Cost share waived for birth control

Medication Lookup Medication Lookup
Express Scripts Mobile App Express Scripts Mobile App
Find a Pharmacy Find a Pharmacy