Blue Preferred

Medical Plan
Schedule of Benefits

	In-Network	Out-of-Network
Annual Deductible Individual Family	$500 $1,000	$1,000 $2,000
Coinsurance	80% after deductible	60% After Deductible
Out of Pocket Maximum Individual Family	$4,000 $9,000	$6,000 $13,000
Office Visits Primary Care Specialist Telemedicine/Virtual Visit	$25 copay $35 copay $25 copay	60% After Deductible
Chiropractic Care Limited to 60 visits per year combined with Physical and Occupational Therapy	$35 copay	Covered at 60% After Deductible
Preventive Care	Covered at 100%; No copay	Covered at 60% After Deductible
Outpatient Physical Therapy/ Occupational Therapy Limited to 60 visits per year combined with Muscle Manipulations	$35 copay	Covered at 60% After Deductible
Emergency Room True Emergency Non-Emergency Urgent Care	Covered at 80% After Deductible Covered at 50% After Deductible $75 copay	Covered at 80% After Deductible Covered at 50% After Deductible Covered at 60% After Deductible
Lab and X-Ray	Covered at 100%; No copay	Covered at 60% After Deductible
Inpatient Hospitalization	Covered at 80% After Deductible	Covered at 60% After Deductible plus $750 deductible per occurrence
Outpatient Surgery	Covered at 80% After Deductible	Covered at 60% After Deductible
Prescription Drugs	30-Day Supply	90-Day Supply (Mail Order)
Generic Preferred Brand Non-Preferred Brand Specialty	$20 $50 $75 $100	$40 $100 $150 Not Available