How it works

Blue Options 1-2-3 divides services into three benefit levels.

Level 1 - Copayments for most primary care office visits and for services like annual exams, immunizations and common diagnostic procedures.^1,2

Level 2 - Provides rich coinsurance coverage for acute care like admitted hospital stays.

Level 3 - A lower level of coinsurance coverage to incent shopping for services like specialist visits and outpatient hospital services.

Prescription drugs - Covered for a copayment or coinsurance.³

Blue Options 1-2-3 Plan Highlights*
Less engagement & cost sharing			More engagement & cost sharing

	LEVEL 1	LEVEL 2	LEVEL 3
Type of Service	Primary care Preventive care	Inpatient care	Outpatient care / Professional specialist care
In-network Copayment or Coinsurance Amounts1	Employees pay $15-25 copayments for Level 1 covered services	Employees pay: $250-500 for each inpatient stay PLUS 0-40% coinsurance for Level 2 covered services after deductible	Employees pay a 10-20% higher level of coinsurance than Level 2 for Level 3 covered services after deductible
In-network Covered Services	Primary care office visits: All covered services, including lab tests and X-rays2 Preventive care:2,4 Routine exams, Immunizations, diagnostic procedures (Pap test, screening mammography and colonoscopy, etc.), well-baby and well-child care, well-woman care, prostate exam	Inpatient hospital services (Admitted hospital stay, including maternity care) Home health care Hospice care Skilled-nursing facility care Inpatient mental health services or substance abuse care Emergency room service (if admitted)	Outpatient hospital services: Lab tests and X-rays, outpatient surgery, therapeutic services (occupational, physical, speech) Emergency room service (if not admitted) Urgent care services Ambulatory surgery services Specialist office visits: Office-based services, including lab tests and X-rays), therapeutic services (occupational, physical, speech) Outpatient mental health services or substance abuse care
Prescription Drug Coverage	Prescription drugs are covered by our standard four-tier design3
Deductible	In-network: $250-5,000 for Individual coverage / $500-10,000 for Family coverage Out-of-network: $500-10,000 for Individual coverage / $1,000-20,000 for Family coverage
Coinsurance Maximum	In-network: $2,000-4,000 for Individual coverage / $4,000-8,000 for Family coverage Out-of-network: $4,000-20,000 for Individual coverage/ $8,000-40,000 for Family coverage

*NOTE: Your actual expenses for covered services may exceed the stated coinsurance percentage or copayment amount because actual provider charges may not be used to determine the health benefit plans and members payment obligations. For out-of-network benefits, you may be required to pay for charges over the allowed amount, in addition to any copayment or coinsurance amount. Pre-existing condition waiting periods may also apply. Pre-existing conditions are those for which medical advice, diagnosis, care or treatment was received or recommended within 12 months of the date that your Blue Options 1-2-3 coverage begins. You may receive credit toward the 12 month waiting period if we receive your completed application within 63 days of the termination of your previous health coverage.