Blue Max (2019)

Blue Max is a comprehensive health plan offered statewide, with extensive coverage for your peace of mind. It has several copayment, coinsurance and deductible plan options to meet your needs.

Preferred Care PPO

NETWORK

=

Blue Max

PLAN

  • GOLD
  • SILVER
  • BRONZE

Here are some plan features and benefits:


Three-tier copayment and coinsurance structure or a two-tier coinsurance structure for prescription drugs, depending on the plan you buy.


Drug deductibles range from $0-500, depending on the plan you buy. If there is no separate drug deductible, medical deductible applies.


We pay 100 percent of preventive care services in network. 


For pediatric dental and vision, $0 for diagnostic and preventive dental and routine eye exams and hardware when received from a network doctor.

Plan Name

Blue Max 90/70 $1,500

G Gold

Blue Max Copay 70/50 $3,000

S Silver

Blue Max Copay 70/50 $3,100

S Silver

Blue Max 80/60 $5,000

B Bronze
Here are the basics:
Deductible (single) $1,500 $3,000 $3,100 $5,000
Deductible (family) $4,500 $9,000 $9,300 $15,000
Most you pay out of pocket (single) $7,900 $7,900 $7,900 $7,900
Most you pay out of pocket (family) $15,800 $15,800 $15,800 $15,800
Coinsurance we pay in network 90% 70% 70% 80%
Coinsurance you pay in network 10% 30% 30% 20%
Coinsurance we pay out of network 70% 50% 50% 60%
Coinsurance you pay out of network 30% 50% 50% 40%
What you'll pay if you go to the following places:
If you go to Primary Care doctor, you pay Deductible then 10% coinsurance $40 per visit $40 per visit Deductible then 20% coinsurance
QBPC, you pay Deductible then 10% coinsurance $25 per visit $25 per visit Deductible then 20% coinsurance
Specialist, you pay Deductible then 10% coinsurance $55 per visit $55 per visit Deductible then 20% coinsurance
Urgent Care, you pay Deductible then 10% coinsurance $55 per visit $55 per visit Deductible then 20% coinsurance
Outpatient ambulatory surgical center, you pay Deductible then 10% coinsurance Deductible then 30% coinsurance Deductible then 30% coinsurance Deductible then 20% coinsurance
Emergency room Deductible then 10% coinsurance Deductible then 30% coinsurance Deductible then 30% coinsurance Deductible then 20% coinsurance
Admitted as inpatient to hospital, you pay Deductible then 10% coinsurance Deductible then 30% coinsurance Deductible then 30% coinsurance Deductible then 20% coinsurance
What you'll pay for prescription drugs and other medical services:
Drug deductible per member No separate drug deductible; medical deductible applies $500 separate drug deductible

$500 separate drug deductible

No separate drug deductible; medical deductible applies
Prescription drugs per fill, you pay

Tier 1: Generic 10% after deductible

Tier 2: Brand 10% after deductible

Tier 1: Generic Drug deductible then $15 copay

Tier 2: Preferred Brand Drug deductible then 20% coinsurance ($250 max)

Tier 3: Non-Preferred Brand Drug deductible then 30% coinsurance ($250 max)

Tier 1: Generic Drug deductible then $15 copay

Tier 2: Preferred Brand Drug deductible then 20% coinsurance ($250 max)

Tier 3: Non-Preferred Brand Drug deductible then 30% coinsurance ($250 max)

Tier 1: Generic 20% after deductible

Tier 2: Brand 40% after deductible

Preventive care services Plan pays 100% in network Plan pays 100% in network Plan pays 100% in network Plan pays 100% in network
Pregnancy care office visit Deductible then 10% coinsurance $55 per visit $55 per visit Deductible then 20% coinsurance
Physical, occupational, speech therapy rehabilitation services Deductible then 10% coinsurance Deductible then 30% coinsurance Deductible then 30% coinsurance Deductible then 20% coinsurance
Mental health and substance use disorder (office visit) Deductible then 10% coinsurance $40 per visit $40 per visit Deductible then 20% coinsurance
Mental health and substance use disorder (inpatient) Deductible then 10% coinsurance Deductible then 30% coinsurance Deductible then 30% coinsurance Deductible then 20% coinsurance
Mental health and substance use disorder (outpatient) Deductible then 10% coinsurance Deductible then 30% coinsurance

Deductible then 30% coinsurance

Deductible then 20% coinsurance
Pediatric dental and vision You will pay $0 for diagnostic and preventive dental and routine eye exams and hardware when received from a network doctor

Plan Name

Blue Max 90/70 $1,500

G Gold
Here are the basics
Deductible (single) $1,500
Deductible (family) $4,500
Most you pay out of pocket (single) $7,900
Most you pay out of pocket (family) $15,800
Coinsurance we pay in network 90%
Coinsurance you pay in network 10%
Coinsurance we pay out of network 70%
Coinsurance you pay out of network 30%
What you'll pay if you go to the following places:
If you go to Primary Care doctor, you pay Deductible then 10% coinsurance
QBPC, you pay Deductible then 10% coinsurance
Specialist, you pay Deductible then 10% coinsurance
Urgent Care, you pay Deductible then 10% coinsurance
Outpatients ambulatory surgical center, you pay Deductible then 10% coinsurance
Emergency room Deductible then 10% coinsurance
Admitted as inpatient to hospital, you pay Deductible then 10% coinsurance
What you'll pay for prescription drugs and other medical services
Drug deductible per member No separate drug deductible; medical deductible applies
Prescription drugs per fill, you pay

Tier 1. Generic 10% after deductible

Tier 2: Brand 10% after deductible

Preventive care services Plan pays 100% in network
Pregnancy care office visit Deductible then 10% coinsurance
Physical, occupational, speech therapy rehabilitation services Deductible then 10% coinsurance

Mental health and substance use disorder (office visit)

Mental health and substance use disorder (inpatient)

Mental health and substance use disorder (outpatient)

Deductible then 10% coinsurance

Deductible then 10% coinsurance

Deductible then 10% coinsurance

Pediatric dental and vision You will pay $0 for diagnostic and preventive dental and routine eye exams and hardware when received from a network doctor

Plan Name

Blue Max Copay 70/50 $3,000

S Silver
Here are the basics
Deductible (single) $2,800
Deductible (family) $8,400
Most you pay out of pocket (single) $7,900
Most you pay out of pocket (family) $15,800
Coinsurance we pay in network 70%
Coinsurance you pay in network 30%
Coinsurance we pay out of network 50%
Coinsurance you pay out of network 50%
What you'll pay if you go to the following places:
If you go to Primary Care doctor, you pay $40 per visit
QBPC, you pay $25 per visit
Specialist, you pay $55 per visit
Urgent Care, you pay $55 per visit
Outpatients ambulatory surgical center, you pay Deductible then 30% coinsurance
Emergency room Deductible then 30% coinsurance
Admitted as inpatient to hospital, you pay Deductible then 30% coinsurance
What you'll pay for prescription drugs and other medical services:
Drug deductible per member $500 separate drug deductible
Prescription drugs per fill, you pay

Tier 1: Generic Drug deductible then $15 copay

Tier 2: Preferred Brand Drug deductible then 20% coinsurance ($250 max)

Tier 3: Non-Preferred Brand Drug deductible then 30% coinsurance ($250 max)

Preventive care services Plan pays 100% in network
Pregnancy care office visit $55 per visit
Physical, occupational, speech therapy rehabilitation services Deductible then 30% coinsurance
Mental health and substance use disorder (inpatient & outpatient)

$40 per visit

Deductible then 30% coinsurance

Deductible then 30% coinsurance

Pediatric dental and vision You will pay $0 for diagnostic and preventive dental and routine eye exams and hardware when received from a network doctor

Plan Name

Blue Max Copay 70/50 $3,100

S Silver
Here are the basics
Deductible (single) $3,100
Deductible (family) $9,300
Most you pay out of pocket (single) $7,900
Most you pay out of pocket (family) $15,800
Coinsurance we pay in network 70%
Coinsurance you pay in network 30%
Coinsurance we pay out of network 50%
Coinsurance you pay out of network 50%
What you'll pay if you go to the following places:
If you go to Primary Care doctor, you pay $40 per visit
QBPC, you pay $25 per visit
Specialist, you pay $55 per visit
Urgent Care, you pay $55 per visit
Outpatients ambulatory surgical center, you pay Deductible then 30% coinsurance
Emergency room Deductible then 30% coinsurance
Admitted as inpatient to hospital, you pay Deductible then 30% coinsurance
What you'll pay for prescription drugs and other medical services:
Drug deductible per member

$500 separate drug deductible

Prescription drugs per fill, you pay

Tier 1: Generic Drug deductible then $15 copay

Tier 2: Preferred Brand Drug deductible then 20% coinsurance ($250 max)

Tier 3: Non-Preferred Brand Drug deductible then 30% coinsurance ($250 max)

Preventive care services Plan pays 100% in network
Pregnancy care office visit $55 per visit
Physical, occupational, speech therapy rehabilitation services Deductible then 30% coinsurance
Mental health and substance use disorder (inpatient & outpatient)

$40 per visit

Deductible then 30% coinsurance

Deductible then 30% coinsurance

Pediatric dental and vision You will pay $0 for diagnostic and preventive dental and routine eye exams and hardware when received from a network doctor

Plan Name

Blue Max 80/60 $5,000

B Bronze
Here are the basics
Deductible (single) $5,000
Deductible (family) $15,800
Most you pay out of pocket (single) $7,900
Most you pay out of pocket (family) $15,800
Coinsurance we pay in network 80%
Coinsurance you pay in network 20%
Coinsurance we pay out of network 60%
Coinsurance you pay out of network 40%
What you'll pay if you go to the following places:
If you go to Primary Care doctor, you pay Deductible then 20% coinsurance
QBPC, you pay Deductible then 20% coinsurance
Specialist, you pay Deductible then 20% coinsurance
Urgent Care, you pay Deductible then 20% coinsurance
Outpatients ambulatory surgical center, you pay Deductible then 20% coinsurance
Emergency room Deductible then 20% coinsurance
Admitted as inpatient to hospital, you pay Deductible then 20% coinsurance
What you'll pay for prescription drugs and other medical services:
Drug deductible per member No separate drug deductible; medical deductible applies
Prescription drugs per fill, you pay

Tier 1: Generic 20% after deductible

Tier 2: Brand 40% after deductible

Preventive care services Plan pays 100% in network
Pregnancy care office visit Deductible then 20% coinsurance
Physical, occupational, speech therapy rehabilitation services Deductible then 20% coinsurance
Mental health and substance use disorder (inpatient & outpatient)

Deductible then 20% coinsurance

Deductible then 20% coinsurance

Deductible then 20% coinsurance

Pediatric dental and vision You will pay $0 for diagnostic and preventive dental and routine eye exams and hardware when received from a network doctor