Health Check Select®
Comprehensive Plan
| Benefit Highlight | Health Check Select |
|---|---|
| Participating Providers | Blue Choice PPO Network Blue Traditional Network |
| Individual Deductible | |
| $200 | √ |
| $500 | √ |
| $1,000 | √ |
| $1,500 | √ |
| $2,500 | √ |
| $5,000 | √ |
| Individual Out-of-Pocket Expense Limits | Blue Choice PPO Network: $1,000 per member Blue Traditional and Out-of-Network: $3,000 per member |
| Coinsurance The percentage you pay for services after deductible and applicable copayments are met. |
You pay 20-30% after deductible |
| Optional Maternity Coverage | Available |
| Optional Dental Coverage | Coverage available from BlueCare Dental PPO |
| Prescription Drugs | You pay 30% after deductible satisfied for in-network pharmacies |
| Prescription Drug Utilization/ Benefit Management Programs (for policies with effective dates on or after 1/1/2012) | 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. |
