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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

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Monthly Premium
$169
$62
Deductible
$0
$250
$0
$350
Primary Care Physician Office Visits
$10 copay
30%
$10 copay
30%
Specialty Office Visit
$25 copay
30%
$35 copay
30%
Urgent Care
$35 copay
$35 copay
$45 copay
$45 copay
Inpatient Hospital Stay
$100 per day for days 1-7
30%
$200 per day for days 1-5
30%
Ambulatory Surgical Center (ASC)
$100 copay
30%
$200 copay
30%
Outpatient Surgery
$200 copay
30%
$300 copay
30%
Emergency Care (copayment waived if admitted)
$100 copay
$100 copay
$80 copay
$80 copay
Labs
$15 copay
30%
$15 copay
30%
X-rays

Outpatient x-ray $20 copay

30%

Outpatient x-ray $25 copay

30%
Diagnostic Radiology (not included x-rays)
$100 copay
30%
$150 copay
30%
Diabetes Self-Monitoring Training and Supplies
No copay
30%
No copay
30%
Hearing Services
$0 copay for routine hearing exam, Limit 1 copay per calendar year ($800 allowance every 3 years for hearing aids)
not covered
$0 copay for routine hearing exams, Limit 1 copay per calendar year ($800 allowance every 3 years for hearing aids)
not covered
Routine Vision Services

$20 copay

One eye exam every calendar year

50%

$20 copay

One eye exam every calendar year

50%
Routine Dental Services
$10 copay (includes: cleaning, bitewing, x-rays (set of two), oral exam)
50%
$10 copay (includes: cleaning, bitewing, x-rays (set of two), oral exam)
50%
Silver&Fit® Fitness Benefit
Included
50%
Included
50%
Durable Medical Equipment
20%
30%
20%
30%
Prescription Drug Benefits
$0 deductible
Over-the-counter
$15 monthly allowance for over-the-counter (OTC) drugs and supplies. Unused allowance may not be carried over from one month to the next. 
$15 monthly allowance for over-the-counter (OTC) drugs and supplies. Unused allowance may not be carried over from one month to the next. 

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Updated October 1, 2017

Y0016_18_400 Pending