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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
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

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
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 
 

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Other Ways to Enroll

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Updated October 1, 2020

Y0016_WBST21_M

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