|
Individuals and Families: Access Blue PPO
|
Access Blue PPO Benefits Summary
With Access Blue PPO you’ll enjoy these benefits:
|
SECTION A: MAJOR MEDICAL SERVICES
|
|
Includes services in the hospital (inpatient and outpatient), skilled nursing
facility, nursing home, ambulatory surgical center, as well as coverage for
home health, durable medical equipment, ambulance and more.
|
| |
|
LIFETIME MAXIMUM
|
$2 Million
|
$2 Million
|
$2 Million
|
|
IN-NETWORK
|
|
|
|
|
DEDUCTIBLE
|
$500
|
$1,000
|
$2,500
|
|
Annual Coinsurance Maximum
|
You pay up to $2,000
|
You pay up to $2,000
|
You pay up to $2,000
|
Annual Out-of-Pocket
Maximum
|
You pay up to $2,500
|
You pay up to $3,000
|
You pay up to $4,500
|
|
OUT-OF-NETWORK*
|
|
|
|
|
DEDUCTIBLE
|
$1,000
|
$2,000
|
$5,000
|
Annual Out-of-Pocket
Coinsurance Maximum
|
You pay up to $4,000
|
You pay up to $4,000
|
You pay up to $4,000
|
Annual Out-of-Pocket
Maximum
|
You pay up to $5,000
|
You pay up to $6,000
|
You pay up to $9,000
|
|
Type of Service
|
In-Network Coinsurance After Deductible
You Pay: When using the True Blue PPO Network
|
|
Inpatient Services (Facility and Physician)
|
20% coinsurance
|
|
Outpatient Services (Facility and Physician)
|
20% coinsurance
|
|
Emergency Room
|
A $200 copayment per visit (whether or not the deductible has been met)
|
|
Adult Wellness
|
20% coinsurance, no deductible to meet, up to a $500 annual maximum
|
|
Child Preventive Care
|
$0
|
|
Ambulance Services
|
20% coinsurance, $1,000 annual maximum
|
|
Home Health Services
|
20% coinsurance, up to a 40-visit annual maximum
|
|
Skilled Nursing Facility (including those services provided in a Nursing Home)
|
20% coinsurance, up to a 30-day annual maximum
|
|
Durable Medical Equipment
|
20% coinsurance, $5,000 annual maximum
|
|
Prosthetic Devices
|
20% coinsurance
|
|
Hospice (requires prior authorization)
|
20% coinsurance
|
|
And More...Regardless of Place of Service
|
|
|
Radiation Therapy Service
|
20% coinsurance
|
|
Chemotherapy
|
20% coinsurance
|
|
Dialysis
|
20% coinsurance
|
|
Diabetes Self-Management Training and Supplies
|
20% coinsurance
|
|
Physical and Occupational Therapy
|
20% coinsurance, up to a 45-visit annual maximum
|
|
Speech Therapy
|
20% coinsurance, up to a 25-visit annual maximum
|
|
*Out-of-Network Coinsurance is 40%. If you go out-of-network, you
will also be responsible for any "balance billing" - in other words, the difference
between the provider's bill and the Arkansas Blue Cross and Blue Shield allowed amount.
|
|
|
SECTION B: OFFICE-BASED SERVICES
|
|
Includes services in the physician's office, stand-alone clinics and independent labs.
|
| |
|
IN-NETWORK
|
|
|
Deductible
|
You pay $5,000 (maximum 2 per family)
|
|
Coinsurance
|
You pay 0%, with no annual maximum after the deductible
|
NOTE: Out-of-network services are not covered
|
These services will be covered based on the type of facility in which they are received —
i.e., Major Medical Services or Office-Based Services:
|
- Allergy testing/therapy
- Injections
- Laboratory tests
- Surgery
- Diagnostic X-rays
|
|
|
|
SECTION C: PRESCRIPTION DRUG BENEFITS**
|
| |
|
Deductible
|
You pay $5,000 (each covered member must meet)
|
|
Coinsurance
|
You pay 0%, with no annual maximum after the deductible
|
|
|
|
**Prescription drug benefit applies to prescriptions that are filled at your
pharmacy.
Please Note: Satisfying one type of deductible (Major Medical Services, Office-Based Services
or Prescription Drug Benefits) does not satisfy any other type of deductible.
Access Blue PPO does not provide coverage for mental health services, including treatment for
alcoholism, drug addiction and psychiatric conditions. Mental health drugs are also not covered
under Access Blue PPO. This includes prescriptions which treat such mental health problems as
attention deficit disorder, attention deficit-hyperactivity disorder, depression, or insomnia.
|
Complete Care
Access Blue PPO prescription drug coverage is based on the Complete Care formulary. This
is a list of covered drugs — both brand-name and generic — that have been carefully
chosen by a committee of practicing physicians and pharmacists. While it does not cover all
medications, the formulary consists of safe and cost-effective drugs approved for most medical
conditions. It is revised periodically to reflect changing drug therapies.
Life Solutions, a term life insurance program, can enhance your existing life
coverage – at a price you can afford. Learn more (130 KB PDF).
Critical Illness Coverage pays a lump sum cash benefit of $10,000, $20,000 or $30,000
upon the first positive diagnosis of a covered critical illness. The benefit can help cover
the costs associated with recovering from a serious illness – including home health care,
experimental medical care, transportation costs to and from treatment, and more. Learn more (130 KB PDF).
*USAble Life is an independent company and operates separately from Arkansas Blue Cross and
Blue Shield. USAble Life does not sell or service Arkansas Blue Cross and Blue Shield
products. USAble Life is solely responsible for the term life and critical illness policies
referenced here.
Important Note: This Web site contains a summary of benefits available to you through
Access Blue PPO; it is not your insurance contract. Please refer to your
policy for a complete list of limitations and exclusions.
|