Blue Care® Elect Deductible Benefits at a Glance
Plan Specifics You Pay (In-Network)
Plan-year deductible $250 (member), $500 (two-person), $750 (family)
Plan-year out-of-pocket maximum for in-network and out-of-network services combined $2,500 (member), $5,000 (family)
Plan-year out-of-pocket maximum for prescription drugs $1,000 (member), $2,000 (family)
Benefit You Pay (In-Network)
Preventive care, routine physicals, GYN, well child, routine hearing and vision exams, family planning Nothing, no deductible
Office visits (sick care and non-preventive) $20 per visit
Office visits (specialists) $35 per visit
Urgent care $35 per visit
Emergency room $100 per visit after deductible (waived if admitted or for observation stay)
Inpatient hospital care

In other general hospitals (as many days as medically necessary)

In higher cost share hospitals (as many days as medically necessary)

$300 per admission after deductible

$700 per admission after deductible

 

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Dependent Benefits

This plan covers dependents to the end of the month in which the dependent turns 26, even if they aren't considered dependents on a tax return and don't attend school, and regardless of whether or not they have a job.

Prescription Drug Coverage

Your plan includes prescription drug coverage. Covered medications are separated into three tiers, and the amount you pay depends on the medication's tier. The plan-year out-of-pocket maximum for prescription drug coverage is $1,000 per member or $2,000 per family.

Prescription Drug Benefits You Pay
Retail pharmacies (up to a 30-day supply) $10 for Tier 11
$25 for Tier 2
$50 for Tier 3
Mail service pharmacy (up to a 90-day supply) $20 for Tier 11
$50 for Tier 2
$110 for Tier 3

1. Cost share waived for Tier 1 birth control

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