SimplyBlue Plans

In-Network

Each plan features the doctors, hospitals and other health care providers who participate in BlueNetwork S. Please use the Find A Doctor tool on this site to see if your doctors participate in BlueNetwork S before applying for one of the plans above.

*Out-of-Pocket Max includes deductible

**This plan qualifies as a high deductible health plan for use with a Health Savings Account

Coinsurance applies to maximum allowable charges. Out-of-pocket maximums for in-network and out-of-network covered services are separate and do not combine. Lifetime maximum benefit - $5,000,000. Any balance of charges (between billed charges and maximum allowable charge) does not apply toward your deductible or out-of-pocket maximum.

Covered Wellness and Preventive Services Subject to Deductible (and coinsurance, if applicable)

• Well child care to age six, including appropriate immunizations, vision and hearing screenings, and other appropriate diagnostics.
• Adult preventive screenings including mammograms, and screenings for cervical and prostate cancer.

Covered Services Subject to Deductible (and coinsurance, if applicable):

• Medically necessary and appropriate services in a practitioner';s office.
• Diagnostic services.
• Injections.
• Inpatient hospitalization including room and board in a semi-private room, general nursing care, medications, injections, diagnostics and special care units.
• Outpatient facility services, including outpatient surgery centers, hospital outpatient centers and outpatient diagnostic centers.
• Emergency care services.
• Skilled nursing and rehabilitation facilities (limited to 30 days per calendar year).
• Therapeutic services including physical therapy, speech therapy, occupational therapy and manipulative therapy (20-visit limit per calendar year, per therapy). Therapeutic services for cardiac and pulmonary rehabilitative services (36-visit limit per calendar year, per therapy).
• Durable medical equipment, prosthetics and orthotics.
• Home health services (40-visit limit per calendar year).
• Ambulance services.
• Hospice.
• Organ Transplants.
• TMJ (non-surgical/$1,500 annual limit).

A 12-month waiting period, from the effective date of the policy, applies to coverage for any pre-existing condition.

Note: Benefits are only paid on medically necessary and appropriate covered services. See your policy for complete coverage details. Certain services require prior authorization. Out-of-network benefits are provided at 50 percent when prior authorization is not obtained. Plan Exclusions

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