Gold Plan (Preferred Blue PPO)

In-network Benefits

• $20 office visit co-pay.
• $30 specialist office visit co-pay.
• $500 Deductible per member, no more than $1,000 per family per calendar year.
• High cost diagnostics (MRI, MRA,, CT CAT, PET & SPECT) - subject to deductible.
• Outpatient surgery - subject to deductible.
• Inpatient - subject to deductible.
• $100 emergency room co-pay & subject to deductible.
• Outpatient Lab, X-ray and Ultrasound services covered in full.
• Skilled Nursing Facility Care - subject to deductible.
• Rehabilitation Facility Care - subject to deductible.
• Preventative Care Immunizations, lead screening, PSA (prostate screening), mammograms and PAP smears covered in full.
• Chiropractic X-rays covered in full.
• Ambulance services (medically necessary emergency transport only) - subject to deductible.
• Durable Medical Equipment (DME) - subject to deductible.

Mental Health and Substance Abuse services must be authorized by Behavioral Health Network at (888) 364-8665:

• Outpatient mental health and substance abuse services $20 co-pay.
• Inpatient mental health and substance abuse services - subject to deductible.

Out-of-network Benefits

$1000 deductible per individual, $3000 per family, per calendar year, then most services covered at 80%. Maximum out-of-pocket $1000 per individual, $3000 per family, per calendar year.

Prescription Drug Benefits

• Retail 30-day supply co-payments - $10 generic drugs,$25 preferred brand name, $40 non-preferred brand name.
• Mail order 90-day supply for certain maintenance rugs - co-payments - $20 generic drugs, $50 preferred brand name,$80 non-preferred brand name.

Please note: this is only a brief summary of coverage. Benefits apply when care is medically necessary. Services are covered up to the Maximum Allowable Benefit (MAB). Network providers agree to accept the MAB as payment in full. However, if you receive services from an out-of-network provider, it is your responsibility to pay the difference between the MAB and the provider's charge.