Page 7 - Empowered Learning for Dyslexic Children Benefits Guide 2022-2023

The Legacy School
Health Insurance Summary Comparison

Effective Date:
February 1, 2022
BlueChoice BlueChoice BlueChoice
Plus HMO HSA HMO HSA
Benefits
Gold $1,000 Silver $1,500 Bronze $6,100
BlueFund BlueFund
In-Network
Referral Needed No No No
Copay
Primary $15 copay Deductible then $25 copay Deductible then $50 copay
Specialist $30 copay Deductible then $50 copay Deductible then $100 copay
Preventive Services
Adult Physical No Charge No Charge No Charge
Well Child Care No Charge No Charge No Charge
Deductible Separate Aggregate Separate
Individual / Family $1,000 / $2,000 $1,500 / $3,000 $6,100 / $12,200
Out of Pocket Separate Separate Separate
Individual / Family $5,570 / $11,500 $6,900 / $13,800 $6,900 / $13,800
Coinsurance 100% 100% 100%
Hospital

In-patient Deductible then $400 copay Deductible then $500 copay Deductible then $500 copay
Out-patient Surgery Deductible then $300 copay Deductible then $500 copay Deductible then $450 copay
Diagnostic (Non-Hospital)
Lab Tests $15 copay Deductible then $25 copay Deductible then $50 copay
Xrays $30 copay Deductible then $50 copay Deductible then $75 copay
Imaging $200 copay Deductible then $250 copay Deductible then $250 copay
Emergency
Emergency Room Deductible then $250 copay Deductible then $250 copay Deductible then $250 copay
Urgent Care Center $50 copay Deductible then $100 copay Deductible then $100 copay
Convenience Care $15 copay Deductible then $25 copay Deductible then $50 copay
Out-of-Network
Deductible Separate
Individual / Family $2,000 / $4,000 N/A N/A
Out-of-Pocket Separate
Individual / Family $11,500 / $23,000 N/A N/A
Coinsurance 100% N/A N/A
Prescription
Deductible/Person $250 except for generic Same as Medical Same as Medical
Generic $10 $15 $10
Preferred Brand $45 $45 $45
Non-preferred Brand $65 $65 $65
Specialty Drugs 50% to max $100 / $150 50% to max $100 / $150 50% to max $100 / $150

Blue Harbor Benefits
(410) 825-3569