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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
	In Network	Out of Network	In Network	Out of Network
	Enroll Online		Enroll Online
Monthly Premium	$170		$49
Deductible	$0	$250	$0	$350
Primary Care Physician Office Visits	$5 copay	$5 copay	$5 copay	$5 copay
Specialty Office Visit	$25 copay	$25 copay	$30 copay	$30 copay
Urgent Care	$35 copay	$35 copay	$45 copay	$45 copay
Inpatient Hospital Stay	$100 per day for days 1-6	$100 per day for days 1-6	$225 per day for days 1-6	$225 per day for days 1-6
Ambulatory Surgical Center (ASC)	$125 copay	$125 copay	$225 copay	$225 copay
Outpatient Surgery	$225 copay	$225 copay	$300 copay	$300 copay
Emergency Care (copayment waived if admitted)	$90 copay	$90 copay	$90 copay	$90 copay
Labs	$10 copay	$10 copay	$10 copay	$10 copay
X-rays	Outpatient x-ray $20 copay	Outpatient x-ray $20 copay	Outpatient x-ray $25 copay	Outpatient x-ray $25 copay
Diagnostic Radiology (not including x-rays)	$125 copay	$125 copay	$200 copay	$200 copay
Diabetes Self-Monitoring Training and Supplies	No copay	20% per item	No copay	20% per item
Hearing Services	$0 copay for routine hearing exam, Limit 1 exam per calendar year ($800 allowance every 3 years for hearing aids)	50 %	$0 copay for routine hearing exams, Limit 1 exam per calendar year ($800 allowance every 3 years for hearing aids)	50%
Routine Vision Services	$20 copay One eye exam every calendar year $125 allowance toward eyeglass frames or contact lenses every 2 years	50%	$20 copay One eye exam every calendar year $125 allowance toward eyeglass frames or contact lenses every 2 years	50%
Expanded Dental Services	$10 copay (includes 2 cleanings, bitewing x-rays (set of two), oral exam)	50%	$10 copay (includes 2 cleanings, bitewing x-rays (set of two), oral exam)	50%
SilverSneakers^® Fitness Benefit	$0 copay	50%	$0 copay	50%
Durable Medical Equipment	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.
Transportation Benefit	24 plan approved round trips		24 plan approved round trips
Meals Benefit – Post Hospital Discharge	2 meals per day for 7 days		2 meals per day for 7 days
In-home Support Services: Grandkids on Demand	5 hours per month included		5 hours per month included
Landmark Health	$0 copay		$0 copay
Medical Nutritional Therapy	$0 copay		$0 copay
Nutritional/Dietary Benefit	$0 copay		$0 copay
Virtual Care	$0 copay		$0 copay
Health Coaching and Education Benefit	$0 copay		$0 copay
	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 — Prime Plan

Annual Notice of Changes — Classic Plan

Out of Network Coverage Rules

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Updated February 10, 2020

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