Simply Blue and Health Check Basic
|Benefit Highlight||Simply Blue||Health Check Basic|
|Participating Providers||Blue Choice PPO Network||Blue Preferred PPO Network
Blue Choice PPO Network
Blue Traditional Network
|Individual Stop-loss Limits/Out-of-Pocket Expense Limits||Individual Stop-loss Limits
$10,000 during the year for covered services. This Stop-loss limit does not apply to expenses incurred for outpatient prescription drugs.
|Individual Out-of-Pocket Expense Limits
Medical: $2,500 per member
Drug: $10,000 per member
The percentage you pay for services after deductible and applicable copayments are met.
You pay 30-50% after deductible
You pay 20-40% after deductible
|Optional Maternity Coverage||Available|
|Optional Dental Coverage||Coverage available from BlueCare Dental PPO||Coverage available from BlueCare Dental PPO|
|Prescription Drugs||You pay $10 for generics and 50% for preferred brand drugs.||You pay 50% for in-network pharmacies. If total charges incurred equal $20,000 in one year on prescription, Health Check Basic will reimburse 100% of allowable charges for the rest of the calendar year.|
|Prescription Drug Utilization/ Benefit Management Programs (for policies with effective dates on or after 1/1/2012)||Not Applicable||Dispensing Limits: Benefits include coverage limits on certain medications. These limits are based on approved guidelines.
Prior Authorization/Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive authorization from BCBSOK and/or certain criteria must be met.
Specialty Pharmacy Program: Specialty medications must be received through the preferred Specialty Pharmacy Provider.
Reminder about coverage for self-administered specialty medications
Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay the share plus the difference in cost.