My Benefits

Benefit Details

Who’s Covered

Plan: Blue Network

See who is covered under your health plan. View your coverage’s effective date, your primary care provider, learn other information such as health plan exclusions and secondary insurance.

Insured Date of Birth Effective Date Other Insurance
Chris Hall 09/04/1970 01/01/2009 Not on File 

What You Pay

Find information on your plan’s In-Network and Out-of-Network Individual and Family deductibles, Out-of-Pocket maximums and lifetime limits. To find information about what’s been met and what’s remaining, visit My Balances.

  Deductible Out-of-Pocket Maximum
Individual Individual
  Lifetime limit per person
In-Network $3500000.00
Out-of-Network $3500000.00
In-Network $1000.00 $3000.00
Out-of-Network $4000.00 $4000.00

What’s Covered

Check your plan’s details. Click on a category and learn about applicable copays, deductibles, coinsurance and limits.

Preventive Care

  Co-Pay Deductible BCBSTPays Limits
Routine Exam $200.00 $90.00 90% Limited to 3 visits per year
Routine Child Care $125.00 $80.00 80% Limited to 2 visits per year
Routine Exam $100.00 $100.00 100% Limited to 2 visit per year
Routine Child Care $100.00 $75.00 75% Limited to 1 visit per year

Office Visits

  Co-Pay Deductible BCBSTPays Limits
Routine Exam $100.00 $75.00 50% Limited to 2 visit per year
Routine Child Care $50.00 $50.00 100% Limited to 1 visit per year
Routine Exam $50.00 $50.00 100% Limited to 1 visit per year
Routine Child Care $60.00 $25.00 50% Limited to 2 visit per year

Emergency

  Co-Pay Deductible BCBSTPays Limits
Routine Exam $500.00 $400.00 80% Limited to 2 visit per year
Routine Child Care $150.00 $75.00 50% Limited to 2 visit per year
Routine Exam $300.00 $150.00 50% Limited to 1 visit per year
Routine Child Care $200.00 $200.00 100% Limited to 1 visit per year

Inpatient Services

  Co-Pay Deductible BCBSTPays Limits
Routine Exam $400.00 $200.00 50% Limited to 2 visit per year
Routine Child Care $200.00 $100.00 50% Limited to 2 visit per year
Routine Exam $100.00 $100.00 100% Limited to 1 visit per year
Routine Child Care $50.00 $50.00 100% Limited to 1 visit per year

Outpatient Services

  Co-Pay Deductible BCBSTPays Limits
Routine Exam $500.00 $400.00 80% Limited to 2 visit per year
Routine Child Care $150.00 $74.00 50% Limited to 1 visit per year
Routine Exam $100.00 $100.00 100% Limited to 2 visit per year
Routine Child Care $50.00 $50.00 100% Limited to 1 visit per year

Medical Equipment

  Co-Pay Deductible BCBSTPays Limits
Routine Exam $400.00 $200.00 50% Limited to 2 visit per year
Routine Child Care $50.00 $50.00 100% Limited to 1 visit per year
Routine Exam $300.00 $150.00 50% Limited to 1 visit per year
Routine Child Care $200.00 $200.00 100% Limited to 1 visit per year

Prescription Drugs

  Co-Pay Deductible BCBSTPays Limits
Routine Exam $400.00 $200.00 50% Limited to 2 visit per year
Routine Child Care $200.00 $200.00 100% Limited to 1 visit per year
Routine Exam $500.00 $400.00 80% Limited to 2 visit per year
Routine Child Care $50.00 $50.00 100% Limited to 1 visit per year

Other

  Co-Pay Deductible BCBSTPays Limits
Routine Exam $200.00 $200.00 100% Limited to 2 visit per year
Routine Child Care $125.00 $80.00 75% Limited to 1 visit per year
Routine Exam $100.00 $100.00 100% Limited to 2 visit per year
Routine Child Care $100.00 $75.00 75% Limited to 1 visit per year

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Healthcare Account Balances

As of 07/23/2014

Flexible Spending Account
Health Care Balance 800.00
Dependent Care Balance 1350.00
Health Reimbursement Arrangement
Balance $350.00

Premium Payment

Amount Due 20000
Due Date 12/12/2010
Last Payment 576.00
Last Payment Date 12/12/2009

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