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You can do a few things right away to get the most from your health plan:
Health plans vary in benefit and complexity. There are several ways to find out what your specific health plan covers:
We negotiate pricing arrangements with our network of healthcare providers on your behalf. Getting care from providers who participate in your plan’s network almost always saves you money. Generally, in-network services are provided at lower rates than out-of-network services. We have the largest network of doctors and hospitals in the state, so quality, in-network care is always nearby. Out-of-network providers usually charge more, so you usually end up paying more.
If you receive care from a doctor or hospital that is out-of-network, you still benefit from having insurance. However, you won’t get the lower cost that we negotiate with in-network providers, meaning you will pay more out-of-pocket.
Preventive screenings look for health conditions or diseases before there are any signs or symptoms. Diagnostic tests are run when your doctor knows you have a health problem but needs to know the cause or extent. Preventive screenings, when run as part of an annual wellness visit, often are covered at little or no cost to you. If you need diagnostic tests, you will likely pay for a portion of the test, according to your benefits (deductible, copay, coinsurance, etc.).
An Explanation of Benefits (EOB) is sent when you visit a doctor, so you can keep track of your healthcare spending. It's not a bill. It is a guide for how to review a bill if your doctor sends you one. You also can see your claims history in our secure, member website Blueprint Portal.
A premium is the fixed amount you pay periodically for your health insurance (health plan) coverage. People with coverage through their employer pay a portion of their premium through payroll deduction.
A deductible is the amount you pay for healthcare before your health plan begins to make payments. For example, if your deductible is $1,000, your health plan will begin paying once you’ve paid $1,000 toward allowable (not billed) charges. An allowable charge is the amount your health plan agrees to pay for a particular healthcare service. The amount reflected on a healthcare provider’s bill may be more, but your deductible is based on what’s allowed. You may have a deductible for each person on your policy and one for your family.
Copayments (copays) are a fixed amount you pay, usually at the time of a medical service. Copays are separate from, and do not count as part of, your deductible. However, they do count toward your out-of-pocket maximum, which can help if you have high medical expenses during a calendar year. Your copay can vary, depending on the type of service you receive (for example, a copay for seeing a specialist may be more than a copay for a primary care visit). You also may have a copay when you get a prescription filled.
Coinsurance is the percentage of the cost you are responsible to pay for healthcare services, after your deductible has been met. For example, you may pay 20% for a service, and your insurance may pay 80%.
No. Copays do not count as part of your deductible.
Deductibles are a form of cost sharing, and they exist to help make health coverage more affordable. If your deductible were eliminated, unless healthcare costs were controlled in some other way, chances are, your price to have health insurance (your premium) would be higher.
The cost of getting care keeps increasing – much more than other costs. This high healthcare inflation affects your premiums. We are constantly working to find ways to keep costs lower for everyone. We have focused on reducing unnecessary or inefficient care, using technology to create efficiencies (virtual health), promoting transparency and rewarding evidence-based care. To understand how health insurers determine annual premiums, see the question "How are premiums determined?" below.
Each year, we develop profiles of members, based on age and gender. We then look at claims data to figure out how much that type of member will cost, based on the average number of doctor visits and health risks we see for members of the same age and gender. Using those profiles, multiplied by the number of covered members, we estimate what the costs will be for the upcoming year. Then we find an average cost per member or family.
Huge medical expenses can be devastating. That’s why out-of-pocket maximums are part of your health plan. If you or a family member have a health crisis, and you reach your out-of-pocket maximum for the calendar year, your insurance will cover you at 100% for the rest of that year. The out-of-pocket limit includes your deductible, coinsurance and copay amounts. The out-of-pocket limit does not include premium payments or charges for services that are not covered.
For example, if your out-of-pocket maximum is $10,000, when you reach this amount, your insurance will cover your services at 100%. Please note that there are separate in-network and out-of-network limits for out-of-pocket maximums. This means you may meet your out-of-pocket maximum for in-network services, but if you receive out-of-network services and have not met that deductible, you still may receive a bill.
A health savings account is a special tax-exempt fund you can use to pay for approved healthcare costs. You or your employer can deposit money into this account. An HSA is a way for you to pay for your qualified healthcare expenses and save for future expenses on a tax-free basis. Your unused money rolls over each year, and you keep what’s in your account even when you switch jobs.
You can view our list of covered drugs, also called a formulary. Our formulary shows all the drugs we cover under all our health plans. View your specific health plan to see which drugs we cover under that plan.
You can use our pharmacy locator to find an in-network pharmacy. You can also call the customer service number on the back of your member ID card.
Drug tiers represent different levels of cost for your medication and can save you money. You pay the least for medications in tiers 1 and 2, which usually are generic drugs. All generic drugs are scientifically proven to be just as effective as brand-name drugs and are typically the same medication as their brand-name equivalents, with identical active ingredients. You will pay more for drugs in the higher tiers, which are brand-name and higher-cost specialty drugs. Find cost information in your health plan's list of covered drugs (also called a formulary).
Step therapy helps patients save money by first trying generic drugs to treat medical conditions. Sometimes a patient may not respond well to a medication (brand-name or generic) and will need to try something different. In step therapy, if that is the case, the patient can ask to move (or “step”) up to a higher-cost medication. It’s just one way we’re trying to save you money while ensuring you the best possible care. You can learn more about step therapy, in our pharmacy section.
Find care, claims & more with our new app.Go mobile