$26 Single
$N/A Family
$61 Single
$N/A Family
$30 Single
$N/A Family
$66 Single
$231 Family
With BluePreferred Basics, you’re covered for basic health care services and you enjoy low monthly payments.
| In Network Single/Family |
Out of Network Single/Family |
|
|---|---|---|
| Deductible (Calendar year) |
$5,000 / NA | $8,000 / NA |
| Coinsurance Max (Calendar year) |
$5,000 / NA | $8,000 / NA |
| Total out-of-pocket (Calendar year, includes deductible) |
$10,000 / NA | $16,000 / NA |
| Coinsurance % for most covered services | 20% Inpatient services | 50% inpatient services |
| Periodic Preventive Services | N/A | |
| Office Visits | N/A | |
| Prescription Drug Coverage | Rx discount card | |
| Accidents | Inpatient only | |
| Maternity care/pregnancy service | Not Covered | |
| Mental illness/substance abuse treatment | Not Covered (Including prescription drugs) | |
| Total contract benefit maximum | $1,000,000 per covered person | |
| In Network Single/Family |
Out of Network Single/Family |
|
|---|---|---|
| Deductible (Calendar year) |
$3,000 / NA | $6,000 / NA |
| Coinsurance Max (Calendar year) |
$3,000 / NA | $6,000 / NA |
| Total out-of-pocket (Calendar year, includes deductible) |
$6,000 / NA | $12,000 / NA |
| Coinsurance % for most covered services | 20% Inpatient / outpatient services | 40% inpatient / outpatient services |
| Periodic Preventive Services | $100 annual benefit | |
| Office Visits | $25 copay (2 annually) | |
| Prescription Drug Coverage | 20% Generic / 40% formulary brand* / 60% non-formulary brand* $3,000 annual maximum (*subject to $1,000 deductible) |
|
| Accidents | $250 annual benefit | |
| Maternity care / pregnancy service | Not Covered | |
| Mental illness / substance abuse treatment | Not Covered (Including prescription drugs) | |
| Total contract benefit maximum | $1,000,000 per covered person | |
| In Network Single/Family |
Out of Network Single/Family |
|
|---|---|---|
| Deductible (Calendar year) |
$2,000 / NA | $5,000 / NA |
| Coinsurance Max (Calendar year) |
$5,000 / NA | $7,000 / NA |
| Total out-of-pocket (Calendar year, includes deductible) |
$7,000 / NA | $12,000 / NA |
| Coinsurance % for most covered services | 30% Inpatient services | 50% inpatient services |
| Periodic Preventive Services | N/A | |
| Office Visits | N/A | |
| Prescription Drug Coverage | Rx discount card | |
| Accidents | $250 annual benefit | |
| Maternity care / pregnancy service | Not Covered | |
| Mental illness / substance abuse treatment | Not Covered (Including prescription drugs) | |
| Total contract benefit maximum | $1,000,000 per covered person | |
| In Network Single/Family |
Out of Network Single/Family |
|
|---|---|---|
| Deductible (Calendar year) |
$0/$0 | $0/$0 |
| Coinsurance Max (Calendar year) |
$10,000 / $20,000 | $20,000 / $40,000 |
| Total out-of-pocket (Calendar year, includes deductible) |
$10,000 / $20,000 | $20,000 / $40,000 |
| Coinsurance % for most covered services | 50% Inpatient / outpatient services | 50% inpatient / outpatient services |
| Periodic Preventive Services | 50% ($200 annual limit) | |
| Office Visits | 50% | |
| Prescription Drug Coverage | 20% Generic / 40% formulary brand* / 60% non-formulary brand* $3,000 annual maximum (*subject to $1,000 deductible) |
|
| Accidents | 50% | |
| Maternity care / pregnancy service | Not Covered | |
| Mental illness / substance abuse treatment | Not Covered (Including prescription drugs) |
|
| Total contract benefit maximum | $1,000,000 per covered person | |
