Industry Plan (Preferred Blue PPO)

In-network Benefits

• $25 office visit co-pay.
• $40 specialist office visit co-pay.
• $1,000 Deductible per member, no more than $2,000 per family per calendar year. 20% Coinsurance up to $2,000 per member, no more than $4,000 per family per calendar year.
• High cost diagnostics (MRI, MRA, CT, CAT, PET & SPECT) subject to deductible and coinsurance.
• Outpatient Lab, X-ray and Ultrasound services covered in full.
• Outpatient Surgery services subject to deductible and coinsurance.
• Inpatient Care subject to deductible and coinsurance.
• Skilled Nursing Facility Care subject to deductible and coinsurance.
• Rehabilitation Facility Care subject to deductible and coinsurance.
• Preventative Care Immunizations, lead screening, PSA (prostate screening), mammograms and PAP smears covered in full.
• Emergency room services $100 co-pay and subject to deductible and coinsurance.
• Chiropractic X-rays covered in full.
• Ambulance services (medically necessary emergency transport only) subject to deductible and coinsurance.
• Durable Medical Equipment (DME), $250 deductible and 20% coinsurance.

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

• Outpatient mental health and substance abuse services $25 co-pay.
• Inpatient mental health and substance abuse services subject to deductible and coinsurance.

Out-of-network Benefits

$2,000 deductible per individual, $6,000 per family, per calendar year, then most services covered at 60%. Maximum out-of-pocket $4,000 per individual, $12,000 per family, per calendar year.

Prescription Drug Benefits

• Retail 30-day supply co-payments - $10 generic drugs, $30 preferred brand name, $50 non-preferred brand name.
• Mail order 90-day supply for certain maintenance rugs - co-payments - $20 generic drugs, $60 preferred brand name, $100 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.