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BlueSimplicity plan options

Regardless of the network you choose, all the products in the table are available. Amounts in the table reflect in-network services only. For PPO plans, additional cost shares will apply to out-of-network services.

With BlueSimplicity, services are grouped into six levels, making it easy for your employees to know their cost share even before receiving services.

  • Level 1 services are free and include preventive services.
  • Level 6 services require higher member copays and cover more serious health needs, such as air ambulance and hospitalizations.
Plan Details BlueSimplicitySM Bronze BlueSimplicitySM Silver BlueSimplicitySM Gold
Annual Benefit — Out-of-pocket maximum (opm) In-network1
Single out-of-pocket maximum $7,900 $7,900 $4,000
Family2 out-of-pocket maximum $15,800 $15,800 $8,000
Level 1

Preventive care3, Blue365® membership, BeWell 24/7SM

Free Free Free
Level 2

Primary care provider (PCP) office visit4, facility lab/X-ray, virtual visit5

$75 $40 $25
Level 3

Non-PCP office visit, outpatient PT/OT/ST, home health care, durable medical equipment

$250 $80 $50
Level 4

Emergency room, ground ambulance, diagnostic imaging/studies6 and radiation therapy

$2,000 $500 $400
Level 5

Outpatient practitioner and facility

$5,500 $4,000 $2,000
Level 6

Hospitalization, air ambulance and skilled nursing facility

$7,900 $6,500 $3,000
Prescription drugs - BlueSimplicitySM Rx
Level 1 (Preventive) Free Free Free
Level 2 $75 $30 $20
Level 3 $250 $200 $75
Level 4 $350 $300 $150
Level 5 $500 $500 $500

Pharmacy Benefits

BlueSimplicitySM RX assigns value to drugs based on their safety, effectiveness and cost compared to medicines that treat the same condition. Level 1 drugs are the best value, while Level 5 drugs have the lowest value and will cost more out-of-pocket. Like the BlueSimplicity medical benefits, your employees will never pay more than the maximum copay amount for the drugs within their assigned level.
Here's how BlueSimplicity Rx works: A drug's safety + its effectiveness + its relative cost = the drug's true value.
1Out-of-pocket costs for in-network services only apply to the in-network out-of-pocket maximum. Only out-of-pocket costs for out-of-network services apply to the out-of-network out-of-pocket maximum.
2The family out-of-pocket maximum (OPM) can be met through any combination of family members. No one member will be required to meet more than the single OPM amount to receive benefits for covered services during a benefit period.
3All costs waived when using an in-network or participating provider on PPO plans. On all other available networks, costs are waived when using an in-network provider. Preventive care includes gynecological exam, preventive exam, screening mammography, well-child care and newborn care. For plans on the Wellmark ValueSM Health Plan HMO Network, a designated personal doctor must be seen for preventive care/screenings and immunizations. One preventive exam with separate gynecological exam per member per benefit period. Well-child care up to age 7 (includes normal newborn care, physical examinations, assessments and immunizations.)
4The primary care office copay applies to family practitioners, general practitioners, internal medicine practitioners, obstetricians/gynecologists, pediatricians, physicians' assistants and advanced registered nurse practitioners. This lower office copay also applies to in-network chiropractors, physical therapists, occupational therapists, speech pathologists, and in some cases, mental health or chemical dependency visits. All other in-network practitioners are subject to the non-primary care office copay. The copay applies per practitioner, per visit.
5The virtual visit copay applies to Doctor On DemandTM.
6Diagnostic imaging includes CT (computerized tomography), MEG (magnetoencephalography), MRAs (magnetic resonance angiography), MRIs (magnetic resonance imaging), PET (positron emission tomography), nuclear medicine and ultrasounds.