BlueJourney HMO

You can select from three BlueJourney HMO plan options. The chart below shows the differences between these plan options. With BlueJourney Essential, you can enjoy this coverage for $0 a month in plan premiums. With all options, there is NO deductible for in-network services.

2017 BlueJourney Premier HMO BlueJourney Value HMO BlueJourney Essential HMO
Monthly Premium $150 $50 $0
Deductible $0 $0 $0
Primary Care Physician Office Visits $10 copay $10 copay $5 copay
Specialist Office Visits $20 copay $25 copay $30 copay
Urgent Care $30 copay $35 copay $40 copay
Inpatient Hospital Stay $65 per day for days 1-5 $100 per day for days 1-5 $170 per day for days 1-8
Ambulatory Surgical Center (ASC) $100 copay $200 copay $250 copay
Outpatient Surgery $200 copay $300 copay $350 copay
Emergency Care
(Copay waived if admitted)
$75 copay $75 copay $75 copay
Labs Freestanding-Independent lab services $0 copay
Outpatient Facility Lab Services $40 copay
Freestanding-Independent lab services $0 copay
Outpatient Facility Lab Services $40 copay
Freestanding-Independent lab services $0 copay
Outpatient Facility Lab Services $40 copay
X-Rays Outpatient X-Rays $25 copay Outpatient X-Rays $25 copay Outpatient X-Rays $50 copay
Diagnostic Radiology (not including X-rays) $75 copay $100 copay $250 copay
Diabetes Self-Monitoring Training and Supplies Covered at 100% Covered at 100% Covered at 100%
Hearing Services $20 copay each per exam and fitting
($800 allowance every 3 years for hearing aids)
$20 copay each per exam and fitting
($800 allowance every 3 years for hearing aids)
$20 copay each per exam and fitting
($800 allowance every 3 years for hearing aids)
Routine Vision $20 copay
One eye exam every calendar year
$20 copay
One eye exam every calendar year
$20 copay
One eye exam every calendar year
Routine Dental Services $10 copay
(includes: cleaning, bitewing x-rays (Set of two), oral exam)
$10 copay
(includes: cleaning, bitewing x-rays (Set of two), oral exam)
$10 copay
(includes: cleaning, bitewing x-rays (Set of two), oral exam)
plus enhanced dental services
Silver&Fit® Fitness Benefit* Included Included Included
Durable Medical Equipment 20% Coinsurance 20% Coinsurance 20% Coinsurance
Prescription Drug Benefits
Over the Counter not covered not covered $25 monthly allowance for Over-the-Counter (OTC) drugs and supplies. Unused allowance may not be carried over from one month to the next. See your OTC brochure for covered items.
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Updated March 3, 2017
Y0016_17_400 Approved 10052016