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BlueJourney PPO

Choose a BlueJourney PPO plan that meets your needs.

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Office visits to your family doctor are covered at a low co-payment. We reimburse you for all medically necessary benefits. It may cost more to get care from out-of-network provides with the exception of emergency and urgent care.

Service Area	BlueJourney Prime PPO		BlueJourney Classic PPO		BlueJourney Select PPO
	In Network	Out of Network	In Network	Out of Network	In Network	Out of Network
	Enroll Online		Enroll Online		Enroll Online
Monthly Premium	$171		$49		$0
Deductible	$0	$250	$0	$350	$0	$750
Primary Care Physician Office Visits - in person and telehealth	$5 copay	$5 copay	$5 copay	$5 copay	$5 copay	$5 copay
Specialty Office Visit - in person and telehealth	$25 copay	$25 copay	$30 copay	$30 copay	$40 copay	$40 copay
Urgent Care	$35 copay	$35 copay	$45 copay	$45 copay	$50 copay	$50 copay
Inpatient Hospital Stay	$100 per day for days 1-6	$100 per day for days 1-6	$225 per day for days 1-7	$225 per day for days 1-7	$335 copay per stay	$335 copay per stay
Ambulatory Surgical Center (ASC)	$125 copay	$125 copay	$225 copay	$225 copay	$300 copay	$300 copay
Outpatient Surgery	$225 copay	$225 copay	$300 copay	$300 copay	$350 copay	$350 copay
Emergency Care - copayment waived if admitted	$90 copay	$90 copay	$90 copay	$90 copay	$90 copay	$90 copay

	BlueJourney Prime PPO		BlueJourney Classic PPO		BlueJourney Select PPO
	In Network	Out of Network	In Network	Out of Network	In Network	Out of Network
Labs	$10 copay	$10 copay	$10 copay	$10 copay	$25 copay	$25 copay
X-rays	Outpatient x-ray $20 copay	Outpatient x-ray $20 copay	Outpatient x-ray $25 copay	Outpatient x-ray $25 copay	Outpatient x-ray $40 copay	Outpatient x-ray $40 copay
Diagnostic Radiology - not including x-rays	$125 copay	$125 copay	$200 copay	$200 copay	$250 copay	$250 copay
Diabetes Self-Monitoring Training and Supplies	No copay	20% per item	No copay	20% per item	No Copay	20% per item
Hearing Services	$0 copay	50% coinsurance	$0 copay	50% coinsurance	$0 copay	50% coinsurance
Hearing Services	For routine hearing exam, Limit 1 exam per calendar year ($800 allowance every 3 years for hearing aids)
Routine Vision Services	$20 copay	50% coinsurance	$20 copay	50% coinsurance	$20 copay	50% coinsurance
Routine Vision Services	One eye exam every calendar year $125 allowance toward eyeglass frames or contact lenses every 2 years
Expanded Dental Services	$10 copay	50% coinsurance	$10 copay	50% coinsurance	$10 copay	50% coinsurance
Expanded Dental Services	Includes 2 cleanings, bitewing x-rays (set of two), oral exam

	BlueJourney Prime PPO		BlueJourney Classic PPO		BlueJourney Select PPO
	In Network	Out of Network	In Network	Out of Network	In Network	Out of Network
SilverSneakers^® Fitness Benefit	$0 copay	50%	$0 copay	50%	$0 copay	50%
Durable Medical Equipment	20%	20%	20%	20%	20%	20%
Prescription Drug Benefits	$0 deductible
Over-the-counter	$25 monthly allowance for over-the-counter (OTC) drugs and supplies. Unused allowance may not be carried over from one month to the next.		$25 monthly allowance for over-the-counter (OTC) drugs and supplies. Unused allowance may not be carried over from one month to the next.		$25 monthly allowance for over-the-counter (OTC) drugs and supplies. Unused allowance may not be carried over from one month to the next.
Transportation Benefit	24 plan approved round trips		24 plan approved round trips		Not covered
Meals Benefit – Post Hospital Discharge	2 meals per day for 7 days		2 meals per day for 7 days		Not covered
In-home Support Services: Grandkids on Demand	5 hours per month included		5 hours per month included		Not covered
Medical Nutritional Therapy	$0 copay		$0 copay		$0 copay
Nutritional/Dietary Benefit	$0 copay		$0 copay		50% OON
Virtual Care	$0 copay		$0 copay		50% OON
Health Coaching and Education Benefit	$0 copay		$0 copay		50% OON
	Enroll Online Other Ways to Enroll		Enroll Online Other Ways to Enroll		Enroll Online Other Ways to Enroll

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Plan Info

Evidence of Coverage

Summary of Benefits

Annual Notice of Changes — Classic Plan

Annual Notice of Changes — Prime Plan

Out of Network Coverage Rules

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Updated October 1, 2020

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