BlueSaver LABI Non-Grandfathered Group Plans
| Effective 1/1/2012 |
| |
Coinsurance |
Out-of-Pocket Maximum
(Includes Deductible) |
|
| |
Deductible |
Network |
Non-Network |
Network |
|
| BlueSaver |
Single |
Family |
|
|
Single |
Family |
Physician Office Visit |
Emergency Room |
Inpatient Hospital |
20 |
$1,200 |
$2,400 |
100/0 |
80/20 |
$3,400 |
$6,800 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
25 |
$1,200 |
$2,400 |
80/20 |
60/40 |
$3,400 |
$6,800 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
4 |
$1,700 |
$3,450 |
100/0 |
80/20 |
$3,350 |
$6,150 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
9 |
$1,700 |
$3,450 |
80/20 |
60/40 |
$3,350 |
$6,150 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
21 |
$1,900 |
$3,800 |
100/0 |
80/20 |
$4,100 |
$8,200 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
26 |
$1,900 |
$3,800 |
80/20 |
60/40 |
$4,100 |
$8,200 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
5 |
$2,500 |
$5,050 |
100/0 |
80/20 |
$3,350 |
$6,150 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
10 |
$2,500 |
$5,050 |
80/20 |
60/40 |
$3,350 |
$6,150 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
22 |
$2,800 |
$5,600 |
100/0 |
80/20 |
$5,000 |
$10,000 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
27 |
$2,800 |
$5,600 |
80/20 |
60/40 |
$5,000 |
$10,000 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
6 |
$3,000 |
$6,000 |
100/0 |
80/20 |
$5,000 |
$10,000 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
11 |
$3,000 |
$6,000 |
80/20 |
60/40 |
$5,000 |
$10,000 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
23 |
$3,300 |
$6,600 |
100/0 |
80/20 |
$5,500 |
$11,000 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
28 |
$3,300 |
$6,600 |
80/20 |
60/40 |
$5,500 |
$11,000 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
7 |
$5,000 |
$10,000 |
100/0 |
80/20 |
$5,100 |
$10,200 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
24 |
$5,500 |
$10,000 |
100/0 |
80/20 |
$5,500 |
$11,000 |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductible then Coinsurance |
Deductibles and Out-of-Pocket Maximums are based on a Calendar Year
All benefits based on allowable charges
This is only an outline. All benefits are subject to the terms and conditions are the contract. In the case of a discrepancy, the contract will prevail.
|
|
