Preventive Visits
$0
$0
$0
$0
HealthyBlue Online Wellness
$0
$0
$0
$0
Doctor Visits
Deductible and coinsurance apply
Deductible and coinsurance apply
Deductible and coinsurance apply
Deductible applies
Chiropractic Care, Physical, Speech and Occupational Therapy
Deductible and coinsurance apply
Deductible and coinsurance apply
Deductible and coinsurance apply
Deductible applies
Prescription Drugs
Preventive Drug: $5
Generics: Deductible and coinsurance apply
Preferred Brand: Deductible and coinsurance apply Non-Preferred Brand: Deductible and coinsurance apply Specialty: Deductible and coinsurance apply
Preventive Drug: $5
Generics: Deductible and coinsurance apply Preferred Brand: Deductible and coinsurance apply Non-Preferred Brand: Deductible and coinsurance apply Specialty: Deductible and coinsurance apply
Preventive Drug: $5
Generics: Deductible and coinsurance apply Preferred Brand: Deductible and coinsurance apply Non-Preferred Brand: Deductible and coinsurance apply Specialty: Deductible and coinsurance apply
Preventive Drug: $5
Generics: Deductible and coinsurance apply Preferred Brand: Deductible and coinsurance apply Non-Preferred Brand: Deductible applies Specialty: Deductible applies
Emergency Room Visit
Deductible and coinsurance apply
Deductible and coinsurance apply
Deductible and coinsurance apply
Deductible applies
Hospitalization
Deductible and coinsurance apply
Deductible and coinsurance apply
Deductible and coinsurance apply
Deductible applies
Deductible
Individual: $2,500 Family: $5,000
Individual: $3,000 Family: $6,000
Individual: $2,800 Family: $5,600
Individual: $6,900 Family: $13,800
Coinsurance
10% of total cost
20% of total cost
20% of total cost
0% of total cost
Out-of-Pocket Maximums
Individual: $4,000 Family: $8,000
Individual: $6,900 Family: $13,800
Individual: $6,900 Family: $13,800
Individual: $6,900 Family: $13,800