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Silver plan details

Regardless of the network you choose, all plans below are available. Amounts in the table reflect covered, in-network services only. For PPO and POS plans, cost shares will apply to out-of-network services. HMO and POS plans may have a variation in benefit costs when employees establish and visit a designated primary care provider (PCP). Steering employees to their designated PCP results in stronger patient-provider relationships and a higher quality of care through patient management.

All plans include easy-to-navigate pharmacy benefits with Blue Rx EssentialsSM. Blue Rx Essentials prescription tiers are designated based on factors like cost and effectiveness when compared to similar drugs.

HMO/POS network

CompleteBlueSM 4000

Deductible

  • Single: $4,000
  • Family: $8,000

Coinsurance: 30%

Out-of-pocket max

  • Single: $9,000
  • Family: $18,000

Medical benefits

Preventive: Free

Virtual visit with Doctor On Demand®: $0

Office services

  • Designated PCP : $35
  • Other PCP: $50
  • Non-PCP: $100

Office-administered specialty medical drug: $150

Hospital services

  • Emergency room: $700
  • Outpatient / Inpatient: 30% after deductible

Blue Rx EssentialsSM

  • Preventive: Free
  • Tier 1: $30
  • Tier 2: $60
  • Tier 3: $150

Specialty

  • Biosimilar / generic: $135
  • Preferred: $150
  • Non-preferred: $500

Medicare Part D Creditable: Yes

CompleteBlueSM 5000

Deductible

  • Single: $5,000
  • Family: $10,000

Coinsurance: 30%

Out-of-pocket max

  • Single: $9,000
  • Family: $18,000

Medical benefits

Preventive: Free

Virtual visit with Doctor On Demand®: $0

Office services

  • Designated PCP: $45
  • Other PCP: $60
  • Non-PCP: $100

Office-administered specialty medical drug: $200

Hospital services

  • Emergency room: $600
  • Outpatient / Inpatient: 30% after deductible

Blue Rx EssentialsSM

  • Preventive: Free
  • Tier 1: $35
  • Tier 2: $70
  • Tier 3: $140

Specialty

  • Biosimilar / generic: $170
  • Preferred: $200
  • Non-preferred: $500

Medicare Part D Creditable: Yes

CompleteBlueSM Primary

Deductible

  • Single: $5,750
  • Family: $11,500

Coinsurance: 30%

Out-of-pocket max

  • Single: $8,900
  • Family: $17,800

Medical benefits

Preventive: Free

Virtual visit with Doctor On Demand®: $0

Office services

  • Designated PCP: $10
  • Other PCP: $25
  • Non-PCP: $100

Office-administered specialty medical drug: 30% after deductible

Hospital services

  • Emergency room: 30% after deductible
  • Outpatient / Inpatient: 30% after deductible

Blue Rx EssentialsSM

  • Preventive: Free
  • Tier 1: $15
  • Tier 2: 30% after deductible
  • Tier 3: 30% after deductible

Specialty

  • Biosimilar / generic: 30% after deductible
  • Preferred: 30% after deductible
  • Non-preferred: 30% after deductible

Medicare Part D Creditable: No

myBlue HDHPSM 5500

Deductible

  • Single: $5,500
  • Family: $11,000

Coinsurance: 0%

Out-of-pocket max

  • Single: $5,500
  • Family: $11,000

Medical benefits

Preventive: Free

Virtual visit with Doctor On Demand®: Deductible applies

Office services: Deductible applies

Office-administered specialty medical drug: Deductible applies

Hospital services: Deductible applies

Emergency room: Deductible applies

Blue Rx Essentials

  • All tiers: Deductible applies

Medicare Part D Creditable: Yes

PPO network

CompleteBlueSM 4000

Deductible

  • Single: $4,000
  • Family: $8,000

Coinsurance: 30%

Out-of-pocket max

  • Single: $9,000
  • Family: $18,000

Medical benefits

Preventive: Free

Virtual visit with Doctor On Demand®: $0

Office services

  • PCP: $40
  • Non-PCP: $100

Office-administered specialty medical drug: $150

Hospital services

  • Emergency room: $700
  • Outpatient / Inpatient: 30% after deductible

Blue Rx Essentials

  • Preventive: Free
  • Tier 1: $30
  • Tier 2: $60
  • Tier 3: $150

Specialty

  • Biosimilar / generic: $135
  • Preferred: $150
  • Non-preferred: $500

Medicare Part D Creditable: Yes

CompleteBlueSM 5000

Deductible

  • Single: $5,000
  • Family: $10,000

Coinsurance: 30%

Out-of-pocket max

  • Single: $9,000
  • Family: $18,000

Medical benefits

Preventive: Free

Virtual visit with Doctor On Demand®: $0

Office services

  • PCP: $50
  • Non-PCP: $100

Office-administered specialty medical drug: $200

Hospital services

  • Emergency room: $600
  • Outpatient / Inpatient: 30% after deductible

Blue Rx Essentials

  • Preventive: Free
  • Tier 1: $35
  • Tier 2: $70
  • Tier 3: $140

Specialty

  • Biosimilar / generic: $170
  • Preferred: $200
  • Non-preferred: $500

Medicare Part D Creditable: Yes

CompleteBlueSM Primary

Deductible

  • Single: $5,750
  • Family: $11,500

Coinsurance: 30%

Out-of-pocket max

  • Single: $8,900
  • Family: $17,800

Medical benefits

Preventive: Free

Virtual visit with Doctor On Demand®: $0

Office services

  • PCP: $15
  • Non-PCP: $100

Office-administered specialty medical drug: 30% after deductible

Hospital services

  • Emergency room: 30% after deductible
  • Outpatient / Inpatient: 30% after deductible

Blue Rx Essentials

  • Preventive: Free
  • Tier 1: $15
  • Tier 2: 30% after deductible
  • Tier 3: 30% after deductible

Specialty

  • Biosimilar / generic: 30% after deductible
  • Preferred: 30% after deductible
  • Non-preferred: 30% after deductible

Medicare Part D Creditable: No

myBlue HDHPSM 5500

Deductible

  • Single: $5,500
  • Family: $11,000

Coinsurance: 0%

Out-of-pocket max

  • Single: $5,500
  • Family: $11,000

Medical benefits

Preventive: Free

Virtual visit with Doctor On Demand®: Deductible applies

Office services: Deductible applies

Office-administered specialty medical drug: Deductible applies

Hospital services: Deductible applies

Emergency room: Deductible applies

Blue Rx Essentials

  • All tiers: Deductible applies

Medicare Part D Creditable: Yes

Virtual Visits with Doctor On Demand®

Reduce absenteeism and costs while increasing employee satisfaction with virtual visits, included in all our plans. Offered at a lower cost than an office visit, Doctor On Demand allows employees to connect face-to-face with a board-certified doctor or mental health professional from virtually anywhere.

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