Blue Health Savings Outline of Benefits

Combined Medical and Prescription Drug Deductible

Outline of Benefits
Benefit Period Calendar Year
Maximum Out-of-Pocket and Co-insurance Options
 
Network Provider Non-Network Provider
Calendar Year Maximum Out-of-Pocket (including Deductible)

After the Calendar Year Maximum Out-of-Pocket is met, applicable in-network expenses are covered at 100% for the remainder of the calendar year.
Individual: $6,550

Family: 2 times the Individual Amount
Not applicable for services rendered by Out-of-Network Providers
Co-insurance Options 80% or 90%
50%
Deductible Options
Calendar Year Combined Medical and Prescription Drug Deductible Options
Deductible must be met before any
Co-insurance amounts apply. If more than one person is covered, the full family Deductible must be met before Co-insurance amounts apply. If the Family Deductible exceeds the Individual Maximum Out-of-Pocket amount, no one covered family member will contribute more that the Individual Out-of-Pocket limit.
Individual: $2,000 or $3,000

Family: 2 times the Individual Amount
Individual: 2 times the Network Amount

Family: 2 times the Non-Network Individual Amount
Health & Wellness
Covered Services Healthy You! Network Provider Non-Network Provider
Healthy You!
Wellness Services based on age and gender.
For a complete listing of the Healthy You! screening guidelines, visit the Healthy You! page.
Other Preventive Health Services as outlined in Medical Policy are also covered.
100% with no co-pay, co-insurance or deductible. Not covered
Covered Services Color Me Healthy! Network Provider Non-Network Provider
Color Me Healthy!
Outpatient Services for eligible Members enrolled in the health management program.
100% Not Covered
Diabetes Treatment

Equipment, supplies for monitoring of blood glucose and insulin administration
Home glucose monitors limited to 1 every 2 calendar years. Prescription Drug Benefits will be provided for diabetic supplies (blood testing, urine testing, and lancets).

Self-Management Training - six (6) hours per calendar year.

Dilated Eye Exam - one exam per calendar year.

Preventive Routine Foot Care - one visit per calendar year.
80% or 90%
Deductible Applies
Not Covered
Prescription Drugs
Benefits are provided for Prescription Drugs included in the Prescription Drug Formulary and Maintenance Formulary.
be RxSmart. it's your choice.sm Community PLUS Pharmacy Non-Community PLUS Pharmacy
Category 1-Generally includes low-cost generic and some brand name drugs. 80% or 90% Not Covered
Category 2-Generally includes higher-cost generic and many brand-name drugs. 80% or 90% Not Covered
Category 3-Generally includes some brand-name drugs and some generic drugs. These drugs may have generic or brand-name alternatives in Category 1 or 2. 80% or 90% Not Covered
Category 4-Generally includes high cost generic drugs, high cost technology drugs and specialty drugs. 80% or 90% Not Covered
Maintenance Medications (90-day supply)

Must use Community PLUS Maintenance Pharmacies
80% or 90%
Not Covered
Generic Only Certain brand name medications will not be covered if there is a generic equivalent. Not Covered
Generic First Certain prescribed medications with generic or lower cost alternative may only be covered if the generic alternative is prescribed first. Not Covered
Disease Specific Drugs
  Network Provider Non-Network Provider
Drugs must be provided by a Network Disease Specific Pharmacy or a Member’s Non-Pharmacy Network Provider, have been Prior Authorized by the Company, and listed in the Disease Specific Drug Formulary
80% or 90%
Not Covered
Medical Services
Prior Authorization must be obtained by a Network Provider for non-emergent elective services provided outside the State of Mississippi unless the member lives out of state.
Centers of Excellence for Specialty Services
Specialty Services include but are not limited to: Cardiac Care; Spine Surgery; and Orthopedic Services. All Specialty Services are subject to prior authorization and are only covered if performed by a Center of Excellence Provider or Specialty Care Designated Network Provider.
Center of Excellence Provider
Specialty Care Designated Network Provider Non-Specialty Care Designated Provider
Co-insurance +10%
Deductible Applies
Co-insurance -10%
Deductible Applies
Not Covered
Hospital Services
Covered Services
Network Provider Non-Network Provider
Inpatient Hospital Services Co-insurance
Deductible Applies
50%
Deductible Applies
Outpatient Hospital Services Co-insurance
Deductible Applies
50%
Deductible Applies
Emergency Room Services -
Non-emergent services are subject to the Non-Network Provider Co-insurance amount.
Co-insurance
Deductible Applies
Co-insurance
Deductible Applies
Newborn Well Baby Care - Exams and routine hospital nursery care of a well newborn. Co-insurance
Deductible Applies
50%
Deductible Applies
Ambulatory Facility Services
Ambulatory Surgical Facility Services
Co-insurance
Deductible Applies
50%
Deductible Applies
Physician and Allied Professional Services
Covered Services
Network Provider Non-Network Provider
Physician (MD or DO) Office Visit Co-insurance Options Primary Care: 80%, 90%
Specialist: 80%, 90%
50%
Deductible Applies
Physician Office Services (MD or DO)
Office Visits Only

Co-insurance
Deductible Applies
50%
Deductible Applies
Other Physician Office Services
Includes, but not limited to injections, x-ray/lab and other services. Does not include Durable Medical Equipment, Prosthetics or Orthotic Devices.
Co-insurance
Deductible Applies
50%
Deductible Applies
Allied Primary Care Health Professional (Nurse Practitioner, Nurse Midwife, Physician Assistant) Office Visits Only
Co-insurance
Deductible Applies
50%
Deductible Applies
Other Allied Office Services
Includes, but not limited to injections, x-ray/lab and other services. Does not include Durable Medical Equipment, Prosthetics or Orthotic Devices.
Co-insurance
Deductible Applies
50%
Deductible Applies
Allied Specialist Office Visits Only*
Co-insurance
Deductible Applies
50%*
Deductible Applies
Other Office Services*
Co-insurance
Deductible Applies
50%*
Deductible Applies
*When Physical Medicine services are provided, Benefits are limited to 20 visits per calendar year and 3 modalities per visit. The limit applies to visits in the home or at the Allied Specialist's office or facility. Benefits are not provided for Physical Medicine Services provided by Non-Network Providers.
Other Allied Services
 
Network Provider Non-Network Provider
Ambulance Services, Allergy Injection/Testing
Co-insurance
Deductible Applies
50%
Deductible Applies
Diagnostic Services Facility, Dialysis Treatment, Durable Medical Equipment, Independent Laboratory, Infusion Therapy, Outpatient Cardiac Rehabilitation, Sleep Studies Co-insurance
Deductible Applies
Not Covered
Hospice Care
Limited to 6 months per lifetime, subject to Care Management
Co-insurance
Deductible Applies
Not Covered
Physical Medicine - Limited to 20 visits per calendar year and 3 modalities per visit. The limit applies to visits in the home or at the Allied Specialist's office or facility. Co-insurance
Deductible Applies
Not Covered
Prosthetics and Orthotic Devices Co-insurance
Deductible Applies
Co-insurance
Deductible Applies
Speech Therapy - Limited to 20 visits per calendar year Co-insurance
Deductible Applies
Co-insurance
Deductible Applies
Therapy Services - Includes chemotherapy, radiation and respiratory. Co-insurance
Deductible Applies
Not Covered
Nervous / Mental Care and Substance Abuse Services
 
Network Provider Non-Network Provider
Inpatient Care Co-insurance
Deductible Applies
50%
Deductible Applies
Partial Hospitalization Co-insurance
Deductible Applies
50%
Deductible Applies
Hospital Outpatient Visits Co-insurance
Deductible Applies
50%
Deductible Applies
Other Outpatient Physician and Allied Professional Services
Co-insurance
Deductible Applies
50%
Deductible Applies
Physician and Allied Professional Office Visits Co-insurance
Deductible Applies
50%
Deductible Applies
Other Services Rendered in Physician and Allied Professional's Office Co-insurance
Deductible Applies
50%
Deductible Applies
Pediatric Dental and Vision Services
Pediatric dental and vision benefits are available for members up to age 19.
Pediatric Dental
Preventive and Diagnostic Services Co-insurance
Deductible Applies
Co-insurance
Deductible Applies
Other Dental Services (as defined within the Benefit Plan) 50%
Deductible Applies
50%
Deductible Applies
Pediatric Vision
Routine Eye Exam Co-insurance
Deductible Applies
Not Covered
Eyeglasses - One pair per year, subject to limitations within the Benefit Plan. 100% up to $150 after Deductible
Not Covered

This summary of the Blue Health Savings Benefit Plan is designed for the purpose of presenting general information about the Benefit Plan and is not intended as a guarantee of benefits. It is not a Summary Plan Description and in the event of a conflict between this document and the actual Benefit Plan, the terms of the Benefit Plan will prevail. All services are subject to Medical Policy and Care Management.