Community Blue LABI Non-Grandfathered Group Plans

Effective 1/1/2012
  Network Co-Pay   Deductible Coinsurance Out-of-Pocket Maximum (Excludes Deductible)
            Network Non-Network Network Non-Network Network Non-Network
LABI Plan PCP* Specialist Urgent Inpatient/Outpatient Facility ER (Network and Non-Network) Single Family Single Family     Single Family Single Family
1 $25 $40 $60 Deductible then Coinsurance $350 $500 $1,500 $5,000 $10,000 80/20 60/40 $2,500 $10,000 $10,000 $15,000
5 $40 $55 $60 Deductible then Coinsurance $350 $1,000 $3,000 $5,000 $10,000 80/20 60/40 $3,500 $7,000 $10,000 $15,000
*PCP copayment applies to Mental Health and Substance Abuse office visits.

 

  • Mental Health and Substance Abuse Professional Services and Outpatient Facility charges are paid at 100%.  Deductible is waived for these benefits.
  • Prosthetic Appliances and Durable Medical Equipment benefits pay at deductible then 80/20 coinsurance.
  • Deductibles and Out-of-Pocket Maximums are based on a calendar year
  • All benefits based on Allowable Charges
  • Refer to brochure for prescription drug benefits.

This is only an outline.  All benefits are subject to the terms and conditions of the Benefit Plan.  In the case of a discrepancy, the Benefit Plan will prevail.  Exclusions and Limitations may apply.