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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 copay per calendar year ($800 allowance every 3 years for hearing aids)
50 %  $0 copay for routine hearing exams, Limit 1 copay 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
Included
50%
Included
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
Included Included
Medical Nutritional Therapy
Included
Included
Nutritional/Dietary Benefit
Included
Included
Virtual Care
Included
Included
Health Coaching and Education Benefit
Included Included

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Updated November 1, 2019

Y0016_WBST1120

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