HealthyBlue 2.0
HealthyBlue 2.0 Summary of Benefits
In-Network You Pay 1
Out-of-Network You Pay 1
Services
DIAGNOSTIC SERVICES
Labs 9
■ Non-Hospital/Freestanding Facility
No charge*
Deductible, then $50 per visit
■ Hospital
Deductible, then $100 per visit
Deductible, then $200 per visit
X-ray 9
■ Non-Hospital/Freestanding Facility
$50 per visit
Deductible, then $50 per visit
■ Hospital
Deductible, then $150 per visit
Deductible, then $200 per visit
Imaging 9
■ Non-Hospital/Freestanding Facility
$100 per visit
Deductible, then $200 per visit
■ Hospital
Deductible, then $200 per visit
Deductible, then $500 per visit
HOSPITALIZATION — (Members are responsible for both physician and facility fees)
Outpatient Surgical Center Services
■ Facility
$100 per visit
Deductible, then $500 per visit
■ Physician
$30 per visit
Deductible, then $50 per visit
Outpatient Hospital Surgical Services
■ Facility
Deductible, then $300 per visit
Deductible, then $500 per visit
■ Physician
Deductible, then $30 per visit
Deductible, then $50 per visit
Inpatient Hospital Services
■ Facility
Deductible, then $300 per day ($1,500 maximum per admission)
Deductible, then $500 per day ($2,500 maximum per admission)
■ Physician
Deductible, then $30 per visit
Deductible, then $50 per visit
HOSPITAL ALTERNATIVES
Home Health Care
Deductible, then $30 per visit
Deductible, then $50 per visit
Hospice (Inpatient — limited to 30 days; Outpatient — unlimited during Hospice eligibilityperiod)
Deductible, then $30 per visit
Deductible, then $50 per visit
Skilled Nursing Facility (limited to 60 days/benefit period)
Deductible, then $30 per admission
Deductible, then $50 per admission
MATERNITY
Preventive Prenatal and Postnatal Office Visits No charge*
Deductible, then $50 per visit
Delivery and Facility Services
Deductible, then $300 per day ($1,500 maximum per admission)
Deductible, then $500 per day ($2,500 maximum per admission)
Artificial and Intrauterine Insemination 5,10
Not covered
Not covered
In Vitro Fertilization Procedures 5,10
Not covered
Not covered
MENTAL HEALTH AND SUBSTANCE USE DISORDER — (Members are responsible for both physician and facility fees)
Office Visits
No charge*
Deductible, then $50 per visit
Outpatient Services
■ Facility
No charge*
Deductible, then $50 per visit
■ Physician
No charge*
Deductible, then $50 per visit
Inpatient Services
■ Facility
Deductible, then $300 per day ($1,500 maximum per admission)
Deductible, then $500 per day ($2,500 maximum per admission)
■ Physician
Deductible, then $30 per visit
Deductible, then $50 per visit
MEDICAL DEVICES AND SUPPLIES
Durable Medical Equipment
No charge* after deductible
Deductible, then 20% of Allowed Benefit
Hearing Aids
Not covered
Not covered
VISION
Routine Exam (limited to 1 visit/benefit period) $10 per visit at participating vision provider
Total charge minus $33 Allowed Benefit
Eyeglasses and Contact Lenses
Not covered
Discounts from participating vision centers
9
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