Page 7 - NAPA 2021-2022

Health Insurance Summary Comparison

BlueChoice BluePreferred
Benefits Plus Gold PPO
$500 Gold $1,000

In-Network
Referral Needed No No
Copay $15 copay
Primary $15 copay
Specialist $30 copay $30 copay
Preventive Services
Adult Physical No Charge No Charge
Well Child Care No Charge No Charge
Deductible Separate Separate
Individual/Family $500 / $1,000 $1,000 / $2,000
Out of Pocket Separate Separate
Individual/Family $7,900 / $15,800 $5,750 / $11,500
Coinsurance 100% 100%
Hospital
In-patient Deductible then $400 copay Deductible then $400 copay
Out-patient Deductible then $300 copay Deductible then $300 copay
Diagnostic (Non-hospital)
Lab Tests $15 copay $15 copay
X-rays $30 copay $30 copay
Imaging $200 copay $200 copay

Emergency
Emergency Room Deductible then $250 copay Deductible then $250 copay
Urgent Care $50 copay $50 copay
Convenience Care $15 copay $15 copay
Out-of-Network
Deductible Separate Separate
Individual/Family $1,000 / $2,000 $2,000 / $4,000
Out of Pocket Separate Separate
Individual/Family $15,800 / $31,600 $11,500 / $23,000
Coinsurance
Prescription
Deductible/Person $250 (waived for generics) $250 (waived for generics)
Generic $10 $10
Preferred Brand $45 $45
Non-preferred Brand $65 $65
Specialty Drugs 50% to max $100 / $150 50% to max $100/$150

Effective Date: 06/01/2021