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BlueJourney PPO

Choose a BlueJourney PPO plan that meets your needs.

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
Select Classic Prime
 
Enroll Online Enroll Online Enroll Online
Monthly premium $0 $50 $172
In-network deductible N/A N/A N/A
Maximum out-of-pocket (MOOP) $7,000(in-network)/$11,300 
(Combined in-network/out-of-network)
$6,700(in-network)/$10,000 
(Combined in-network/out-of-network)
$5,000(in-network)/$10,000 
(Combined in-network/out-of-network)
Doctor and hospital choice In and out-of-network benefits, includes visitor/traveler benefits In and out-of-network benefits, includes visitor/traveler benefits In and out-of-network benefits, includes visitor/traveler benefits
Primary Care Physician office visits - in person or telehealth $5 copay $5 copay $5 copay
Physician specialist - in person or telehealth $40 copay $30 copay $25 copay
Urgent care $50 copay $45 copay $35 copay
Inpatient hospital stay $325 copay per stay $240 per day for days 1-5 $125 per day for days 1-5
Outpatient Surgery $350 copay $300 copay $225 copay
Ambulatory Surgical Center (ASC) $350 copay $225 copay $125 copay
Emergency care $90 copay $90 copay $90 copay
Lab services $0-$25 copay/visit (in-network) 
20% coinsurance (out-of-network)
$0-$20 copay/visit (in-network) 
20% coinsurance (out-of-network)
$0-$20 copay/visit (in-network and out-of-network)
X-rays $40 copay/visit (in-network) 
20% coinsurance (out-of-network)
$25 copay visit (in-network) 
20% coinsurance (out-of-network)
$20 copay/visit (in-network and out-of-network)
High-tech imaging (MRI/CT scan) $275 copay/visit (in-network) 
20% coinsurance (out-of-network)
$230 copay/visit (in-network) 
20% coinsurance (out-of-network)
$125 copay/visit (in-network and out-of-network)
Diabetes self-monitoring training and supplies $0 copay (in-network) 
20% coinsurance (out-of-network)
$0 copay (in-network) 
20% coinsurance (out-of-network)
$0 copay (in-network) 
20% coinsurance (out-of-network)
Hearing services 
(routine fitting and exam)
$0 copay annual routine exam 
$0 copay fitting/3 years (in-network) 
50% coinsurance (out-of-network)
$0 copay annual routine exam 
$0 copay fitting/3 years (in-network) 
50% coinsurance (out-of-network)
$0 copay annual routine exam 
$0 copay fitting/3 years (in-network) 
50% coinsurance (out-of-network)
Hearing aids $800 allowance/3 years $800 allowance/3 years $800 allowance/3 years
Vision services 
routine exam (one annual exam)

$20 copay/visit (in-network) 
50% coinsurance (out-of-network)

$20 copay/visit (in-network) 
50% coinsurance (out-of-network)

$20 copay/visit (in-network) 
50% coinsurance (out-of-network)

Vision services hardware allowance and contact lenses coverage1

$125 allowance for eyeglass frames or contact lenses every year

$125 allowance for eyeglass frames or contact lenses every year

$125 allowance for eyeglass frames or contact lenses every year

Dental benefits $10 copay(in-network) cleaning and X-rays covered, two cleanings per calendar year 
50% coinsurance out-of-network for preventive 
50% coinsurance combined in-network/out-of-network for nonroutine, restorative, endodontics, and non-surgical extractions services 
$2,000 annual allowance
$10 copay(in-network) cleaning and X-rays covered, two cleanings per calendar year 
50% coinsurance out-of-network for preventive 
50% coinsurance combined in-network/out-of-network for nonroutine, restorative, endodontics, and non-surgical extractions services 
$2,000 annual allowance
$10 copay(in-network) cleaning and X-rays covered, two cleanings per calendar year 
50% coinsurance out-of-network for preventive 
50% coinsurance combined in-network/out-of-network for nonroutine, restorative, endodontics, and non-surgical extractions services 
$2,000 annual allowance
SilverSneakers®2 $0 copay $0 copay $0 copay
Flexible debit card for over-the-counter drugs and supplies (OTC)3 $25 per month retail or mail order (cannot be carried over from month to month) $25 per month retail or mail order (cannot be carried over from month to month) $25 per month retail or mail order (cannot be carried over from month to month)

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Plan Info

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1Payment will be made for either frames or contact lenses within a benefit period. Payment will not be made for both.

2Must use a SilverSneaker® facility.

3Qualifying OTC retailers Walmart, Rite Aid, CVS, and Walgreens.

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Updated October 1, 2021

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