BlueChoice BlueEdge H.S.A. MMH1Y20
IN-NETWORK BENEFITS:
MEMBER SERVICES: 1-800-521-2227
CALENDAR YEAR DEDUCTIBLE: $2,800 Individual ($5,600 Family)
CALENDAR YEAR OUT-OF-POCKET MAX: $2,700 Individual ($5,400 Family)
(Both medical and drug expenses count toward the deductible).
Preventive Care: No deductible. No charge.
Primary Care Dr Visits: No charge after deductible.
Specialist Office Visits: No charge after deductible.
CT and PET Scans, MRI's: No charge after deductible.
Diagnostic X-rays / blood: No charge after deductible.
IN-PATIENT: No charge after deductible.
OUT-PATIENT: No charge after deductible.
Skilled Nursing Facility: No charge after deductible. Max 25 days per calendar year.
DRUGS: No charge after deductible. (Some drugs require pre-authorization).
EMERGENCY ROOM SERVICES: No charge after deductible.
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Unless it would delay emergency care, you must get written pre-authorization two working days before receiving care, for the following care. In-network doctors normally obtain pre-authorization.
1. All in-patient admissions.
2. Extended Care Expense.
3. Home Infusion Therapy.
4. Diagnostic Studies for Obstructive Sleep Apnea.
5. Out-patient Radiation Therapy.
6. All-inpatient treatment of chemical dependency, serious mental illness, and mental health care.
7. Moving from one medical facility to another, including a specialty unit within the same facility.
You need to obtain pre-authorization for the following OUT-PATIENT CARE:
1. Psychological testing.
2. Neuro-psychological testing.
3. Electro-convulsive therapy.
4. Repetitive transcranial magnetic stimulation.
5. Applied behavioral analysis.
6. Intensive Out-patient program.
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NON-NETWORK BENEFITS Usual and reasonable charges apply.
Beware! Non-network providers can charge considerably higher amounts and bill you for any amount above what the insurance carrier pays.
CALENDAR YEAR DEDUCTIBLE: $5,200 Individual ($10,400 Family)
CALENDAR YEAR OUT-OF-POCKET MAX: $10,400 Individual ($20,800 Family)
Primary Care or Specialist Office Visit: Non-Network Deductible + 30%.
CT Scans, PET Scans, MRI's: Non-Network Deductible + 30%.
Diagnostic X-ray or blood work: Non-Network Deductible + 30%.
HOSPITALIZATION: Non-Net Deductible + 30%.
OUT-PATIENT: Non-Net Deductible + 30%.
Drugs: No charge after non-network deductible.
EMERGENCY ROOM SERVICES: No charge after deductible.
This is a general summary only. Plan documents take precedence.
