Web Content Viewer - Metadata
Web Content Viewer - Fixed Context
Web Content Viewer - Fixed Context
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) |
$20 copay/visit (in-network) |
$20 copay/visit (in-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) |
Web Content Viewer - Fixed Context
Plan Info
Web Content Viewer - Fixed Context
Web Content Viewer - Fixed Context
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.
Web Content Viewer - Fixed Context
Updated January 4, 2022
Y0016_22WBSTJan_M