$85 Single
$249 Family
$94 Single
$274 Family
$96 Single
$279 Family
$104 Single
$304 Family
$111 Single
$324 Family
BlueEssentials is a set of budget-friendly plans that covers your essential health care needs with the options you want - coverage for inpatient and outpatient hospital services, prescription drugs and much more!
| In Network Single/Family |
Out of Network Single/Family |
|
|---|---|---|
| Deductible (Calendar year) |
$3,500/$7,000 | $7,000/$14,000 |
| Coinsurance Max (Calendar year) |
$2,500/$5,000 | $6,000/$12,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$6,000/$12,000 | $13,000/$26,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Office visits and related services | $40 | 40% |
| Routine Preventive Care | ||
| Periodic Exams | $40 Copay | 40% |
| Routine Mammograms | Covered @ 100% | 40% |
| Routine Pap Smears | Covered @ 100% | 40% |
| Routine Immunizations | Covered @ 100% | 40% |
| Coinsurance % for maternity benefits* | Not Covered (unless added as an optional benefit) | |
| Mental illness/substance abuse treatment | Not Covered (including prescription drugs) | |
| Prescription Drug Coverage | $0 generic $30 brand formulary $60 non-brand formulary |
|
| Accident Benefit | $300 first dollar per covered person per year | |
| Total contract benefit maximum | $10 million per covered person | |
| In Network Single/Family |
Out of Network Single/Family |
|
|---|---|---|
| Deductible (Calendar year) |
$2,000/$4,000 | $4,000/$8,000 |
| Coinsurance Max (Calendar year) |
$2,500/$5,000 | $6,000/$12,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$4,500/$9,000 | $10,000/$20,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Office visits and related services | $40 | 40% |
| Routine Preventive Care | ||
| Periodic Exams | $40 Copay | 40% |
| Routine Mammograms | Covered @ 100% | 40% |
| Routine Pap Smears | Covered @ 100% | 40% |
| Routine Immunizations | Covered @ 100% | 40% |
| Coinsurance % for maternity benefits* | Not Covered (unless added as an optional benefit) | |
| Mental illness/substance abuse treatment | Not Covered (including prescription drugs) | |
| Prescription Drug Coverage | $0 generic $30 brand formulary $60 non-brand formulary |
|
| Accident Benefit | $300 first dollar per covered person per year | |
| Total contract benefit maximum | $10 million per covered person | |
| In Network Single/Family |
Out of Network Single/Family |
|
|---|---|---|
| Deductible (Calendar year) |
$1,500/$3,000 | $3,000/$6,000 |
| Coinsurance Max (Calendar year) |
$2,500/$5,000 | $6,000/$12,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$4,000/$8,000 | $9,000/$18,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Office visits and related services | $40 | 40% |
| Routine Preventive Care | ||
| Periodic Exams | $40 Copay | 40% |
| Routine Mammograms | Covered @ 100% | 40% |
| Routine Pap Smears | Covered @ 100% | 40% |
| Routine Immunizations | Covered @ 100% | 40% |
| Coinsurance % for maternity benefits* | Not Covered (unless added as an optional benefit) | |
| Mental illness/substance abuse treatment | Not Covered (including prescription drugs) | |
| Prescription Drug Coverage | $0 generic $30 brand formulary $60 non-brand formulary |
|
| Accident Benefit | $300 first dollar per covered person per year | |
| Total contract benefit maximum | $10 million per covered person | |
| In Network Single/Family |
Out of Network Single/Family |
|
|---|---|---|
| Deductible (Calendar year) |
$1,000/$2,000 | $2,000/$4,000 |
| Coinsurance Max (Calendar year) |
$2,000/$4,000 | $5,000/$10,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$3,000/$6,000 | $7,000/$14,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Office visits and related services | $40 | 40% |
| Routine Preventive Care | ||
| Periodic Exams | $40 Copay | 40% |
| Routine Mammograms | Covered @ 100% | 40% |
| Routine Pap Smears | Covered @ 100% | 40% |
| Routine Immunizations | Covered @ 100% | 40% |
| Coinsurance % for maternity benefits* | Not Covered (unless added as an optional benefit) | |
| Mental illness/substance abuse treatment | Not Covered (including prescription drugs) | |
| Prescription Drug Coverage | $0 generic $30 brand formulary $60 non-brand formulary |
|
| Accident Benefit | $300 first dollar per covered person per year | |
| Total contract benefit maximum | $10 million per covered person | |
| In Network Single/Family |
Out of Network Single/Family |
|
|---|---|---|
| Deductible (Calendar year) |
$500/$1,000 | $1,000/$2,000 |
| Coinsurance Max (Calendar year) |
$2,000/$4,000 | $5,000/$10,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$2,500/$5,000 | $6,000/$12,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Office visits and related services | $40 | 40% |
| Routine Preventive Care | ||
| Periodic Exams | $40 Copay | 40% |
| Routine Mammograms | Covered @ 100% | 40% |
| Routine Pap Smears | Covered @ 100% | 40% |
| Routine Immunizations | Covered @ 100% | 40% |
| Coinsurance % for maternity benefits* | Not Covered (unless added as an optional benefit) | |
| Mental illness/substance abuse treatment | Not Covered (including prescription drugs) | |
| Prescription Drug Coverage | $0 generic $30 brand formulary $60 non-brand formulary |
|
| Accident Benefit | $300 first dollar per covered person per year | |
| Total contract benefit maximum | $10 million per covered person | |
