Page 7 - Public Citizen 2021-2022

P. 7

,ĞĂůƚŚ /ŶƐƵƌĂŶĐĞ ^ƵŵŵĂƌǇ ŽŵƉĂƌŝƐŽŶ

Blue Preferred
ĞŶĞĮƚƐ
Option 1

/ŶͲEĞƚǁŽƌŬ
Referral Needed EŽ
Copay
Primary $10 Copay
^ƉĞĐŝĂůŝƐƚ $10 copay

WƌĞǀĞŶƟǀĞ ^ĞƌǀŝĐĞƐ
ĚƵůƚ WŚǇƐŝĐĂů EŽ ŚĂƌŐĞ
tĞůů ŚŝůĚ ĂƌĞ EŽ ŚĂƌŐĞ

ĞĚƵĐƟďůĞ
/ŶĚŝǀŝĚƵĂůͬ&ĂŵŝůǇ N/A
KƵƚ ŽĨ WŽĐŬĞƚ
/ŶĚŝǀŝĚƵĂůͬ&ĂŵŝůǇ $1,000 / $2,000
ŽŝŶƐƵƌĂŶĐĞ 100%
,ŽƐƉŝƚĂů Paid in Full
/ŶͲƉĂƟĞŶƚ
KƵƚͲƉĂƟĞŶƚ Paid in Full
ŝĂŐŶŽƐƟĐ ;EŽŶͲŚŽƐƉŝƚĂůͿ
>Ăď dĞƐƚƐ Paid in Full
X-rays Paid in Full
/ŵĂŐŝŶŐ Paid in Full

Emergency
ŵĞƌŐĞŶĐǇ ZŽŽŵ $50 copay
hƌŐĞŶƚ ĂƌĞ $10 copay
ŽŶǀĞŶŝĞŶĐĞ ĂƌĞ $10 copay
KƵƚͲŽĨͲEĞƚǁŽƌŬ

ĞĚƵĐƟďůĞ
/ŶĚŝǀŝĚƵĂůͬ&ĂŵŝůǇ $30Ϭ / $600
KƵƚ ŽĨ WŽĐŬĞƚ Ψ2,000 / $4,000
/ŶĚŝǀŝĚƵĂůͬ&ĂŵŝůǇ
ŽŝŶƐƵƌĂŶĐĞ 80% / 20%
WƌĞƐĐƌŝƉƟŽŶ
ĞĚƵĐƟďůĞͬWĞƌƐŽŶ $0
'ĞŶĞƌŝĐ $8
WƌĞĨĞƌƌĞĚ ƌĂŶĚ $15
EŽŶͲƉƌĞĨĞƌƌĞĚ ƌĂŶĚ Ψ30
^ƉĞĐŝĂůƚǇ ƌƵŐƐ N/A

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ 07/ϬϭͬϮϬϮ1

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