Benefit Comparison Chart

Benefit Comparison Chart

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2021 - 2022 Benefits Comparison

Medical/Surgical Care by a Physician

Office Services
Health Plan  In-Network Family Physician In-Network Specialist

Out-of-Network
BlueCare HMO 58 $40 $60

Not Covered
BlueOptions PPO03769 $40 $60 DED + 40%
 

BlueOptions PPO 05190 & HSA

(Acct. Funding: EE Only=$500)

 DED + 20% DED + 20% DED + 40%

BlueOptions PPO 05191 & HSA Family Plan

(Acct. Funding: EE+1=$1,000 or EE+2=$1,500)

 DED + 20% DED + 20% DED + 40%

Physician Services at Hospital
Health Plan  In-Network   Out-of-Network
BlueCare HMO 58 $0 Not Covered
BlueOptions PPO03769 DED + 20% INN DED + 20%
 

BlueOptions PPO 05190 & HSA

(Acct. Funding: EE Only=$500)

 DED + 20% INN DED + 20%

BlueOptions PPO 05191 & HSA Family Plan

(Acct. Funding: EE+1=$1,000 or EE+2=$1,500)

 DED + 20% INN DED + 20%