2017 BlueJourney PPO

You may select from two BlueJourney PPO plan options. Office visits to your family doctor are covered at a low co-payment for both options. We provide reimbursement for all covered benefits, as long as they are medically necessary. With the exception of emergency and urgent care, it may cost more to get care from out-of-network providers.

BlueJourney Prime PPO BlueJourney Classic PPO
  In Network Out of Network In Network Out of Network
Monthly Premium $175 $55
Deductible $0 $250 $0 $350
Primary Care Physician Office Visits $10 copay 30% $10 copay 30%
Specialty Office Visits $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 1-7 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)
$75 copay $75 copay $75 copay $75 copay
Labs Freestanding-Independent lab services $0 copay
Outpatient Facility Lab Services $40 copay
30% Freestanding-Independent lab services $0 copay
Outpatient Facility Lab Services $40 copay
30%
X-Rays Outpatient X-Ray $20 copay 30% Outpatient X-Ray $25 copay 30%
Diagnostic Radiology (not including X-rays) $100 copay 30% $150 copay 30%
Diabetes Self-Monitoring Training and Supplies No copay 30% No copay 30%
Hearing Services $20 copay for routine hearing exam. ($800 allowance every 3 years for hearing aids) 50% $20 copay for routine hearing exam. ($800 allowance every 3 years for hearing aids) 50%
Routine Vision $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
Televisit Benefit $5 copay $8 copay
Over The Counter not covered $15 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.
Enroll Enroll

Updated March 3, 2017
Y0016_17_400 Approved 10052016