A Wise Plan

Benefits

BlueBasic

BlueAdvantage

Deductibles. Once an individual deductible is met benefits begin for that member, OR when the family sugarbowl (aggregate) deductible is met, benefits begin for the entire family. No one member can contribute more than his or her individual deductible towards the family deductible.

Out-Of-Pocket (OOP) Maximums. Deductible amounts and other OOP expenses as defined by the plan apply to the OOP Max. Copayments and Mental Health Coinsurance do not apply towards OOP Max.

Ded.	Ind. OOP Max	Family Ded.	Fam. OOP Max

$250	$3,000	$750	$6,000
$500	$4,000	$1,000	$8,000
$1,000	$5,000	$2,000	$10,000
$2,500	$6,000	$5,000	$11,000
$5,000	$7,000	$10,000	$13,000
$7,500	$10,000	$15,000	$18,000

Ded.	Ind. OOP Max	Family Ded.	Fam. OOP Max

$250	$2,500	$750	$5,000
$500	$3,000	$1,000	$6,000
$1,000	$3,500	$2,000	$7,000
$2,500	$4,000	$5,000	$8,000
$5,000	$6,500	$10,000	$12,000
$1,500	$9,000	$15,000	$17,000

Coinsurance

In-Network

Out-Of-Network

70% / 30%
55% / 45%

80% / 20%
60% / 40%

Maximum Benefits

$2 Million

Professional Services:

Office/Clinic and Urgent care Center

Including Minor Surgical Procedures and Diagnostic Tests

Including Preventive Services

Low Ded. Plans	High Ded.Plans

After $30 Copayment, We Pay 100% of EME.	After Ded., We Pay 70% and You Pay 30% of EME

Low Ded. Plans	High Ded.Plans

After $20 Copayment, We Pay 100% of EME.	After Ded., We Pay 80% and You Pay 20% of EME

Inpatient and Outpaitent Professional Care

Outpatient Rehab and Chiropractic Care

Chemotherapy, Radiation and Dialysis

Major Surgical Procedures and Major Diagnostic Tests

Professional services not otherwise specified

After Deductible, We pay 70% and you pay 30% of EME.

After Deductible, We pay 80% and you pay 20% of EME.

Facility Services:

Inpatient Hospital/SNF, Outpatient Hospital Care

Major Diagnostic Tests

Ambulatory Service Facility

Home Health Care

Home Infusion Therapy

After Deductible, We pay 70% and you pay 30% of EME.

After Deductible, We pay 80% and you pay 20% of EME.

Emergency Department

After Deductible and $100 Copayment, We Pay 70% and You Pay 30% of EME.

After Deductible and $75 Copayment, We Pay 80% and You Pay 20% of EME.

Other Covered Services:

Mental Health Condition Services
(including use/abuse of alcohol/drugs)

After Deductible, 50% to Maximum Benefits of $1,500. Coinsurance does not apply to out-of-pocket maximum.

DME and Supplies, Prosthetic and Othotic Devices

After Deductible, We pay 70% and you pay 30% of EME.

After Deductible, We pay 80% and you pay 20% of EME.

Maternity Care

All Covered Services

After $5,000 Copayment, We pay 100% (Copayment does not apply to out-of-pocket maximum.)

Additional Benefits:

Supplemental Accident Benefit

N/A

$1,000 per member per calendar year.

Rx Card

Rx Ded.

Rx Classes

Rx Copayment

Rx Ded.

Rx Classes

Rx Copayment

	$250 Medical Deductible

	$500 Medical Deductible

	$1,000 Medical Deductible

$100	Generic Formulary Non-Form.	$10 25% 50%

$200	Generic Formulary Non-Form.	$10 25% 50%

$400	Generic Formulary Non-Form.	$10 25% 50%

N/A	Generic Formulary Non-Form.	$5 25% 50%

N/A	Generic Formulary Non-Form.	$5 25% 50%

N/A	Generic Formulary Non-Form.	$5 25% 50%

	$2,500 Medical Deductible

	$5,000 Medical Deductible

	$7,500 Medical Deductible

Your Identification card also works as a discount card at the pharmacy. Present your card at the pharmacy, pay 100% of the discounted amount, and then submit you receipt to Us. Prescription drugs will then be reimbursed at 70% after the medical plan Deductible per Calendar Year has been met. The Member's 30% Coinsurance can be applied toward the Out-of-Pocket Maximum.