Simply Blue and Health Check Basic
Budget-Conscious Plans
| 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 Deductible | ||
| $500 | √ | |
| $1,000 | √ | √ |
| $2,500 | √ | √ |
| $3,500 | √ | √ |
| $5,000 | √ | √ |
| $7,500 | √ | √ |
| $10,000 | √ | |
| 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 |
| Coinsurance 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. |
