2023 Blue Advantage (PPO) Plan 004 - $100 per month


PPO plan available statewide.

 $0 deductible for in-network medical services

 $925 Mastercard® Flex Card to pay for out-of-pocket expenses

 $0 in-network primary care visits, including online visits with BlueCare

 $0 deductible for prescription drugs

 $0 copay for a three-month supply of Tier 1 drugs at a preferred retail pharmacy or by mail order

 See a specialist without a referral

 Dental, vision, hearing, fitness center membership, over-the-counter supplies

 With a PPO plan, you can get care from out-of-network providers, but your costs may be higher

In-Network Medical
& Hospital Benefits
  PPO*
Premium $100 Per Month
Medical Deductible $0 Per Year
Preventive Care $0 Copay
Primary Care Visits $0 Copay
Specialist Visits $40 Copay
Urgent Care $35 Copay
Emergency Room Care $90 Copay
Inpatient Hospital Care $140 Per Day for Days 1-10; $0 Per Day for Days 11-90 (per admit)
Outpatient Hospital Surgery $200 Copay
Maximum Out-of-Pocket Limit $4,000 Per Year

*For our PPO plans, if you use an out-of-network provider, your share of the costs for your covered services may be higher. Out-of-network/non-contracted providers are under no obligation to treat Blue Advantage members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Premium Blue Advantage (PPO) Prescription Drug Benefits*
Deductible $0 prescription drug deductible
Preferred Retail and Mail-Order Cost-Sharing
Tier One-Month Supply Two-Month Supply Three-Month Supply
Tier 1 (Preferred Generics) $3 copay $6 copay $0 copay
Tier 2 (Generics) $12 copay $24 copay $36 copay
Tier 3 (Preferred Brand) $45 copay $90 copay $135 copay
Tier 4 (Non-Preferred Drug) $100 copay $200 copay $300 copay
Tier 5 (Specialty) 33% coinsurance Not Offered Not Offered
Standard Retail and Mail-Order Cost-Sharing
Tier One-Month Supply Two-Month Supply Three-Month Supply
Tier 1 (Preferred Generics) $10 copay $20 copay $30 copay
Tier 2 (Generics) $18 copay $36 copay $54 copay
Tier 3 (Preferred Brand) $47 copay $94 copay $141 copay
Tier 4 (Non-Preferred Drug) $100 copay $200 copay $300 copay
Tier 5 (Specialty) 33% coinsurance Not Offered Not Offered

*For in-network pharmacies only

For our PPO plans, if you use an out-of-network provider, your share of the costs for your covered services may be higher. Out-of-network/non- contracted providers are under no obligation to treat Blue Advantage members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services.

Plan Features to Help Keep You Healthy
(HMO & PPO)*
Flex Card $925 Mastercard® Flex Card to help pay for out-of-pocket costs, including:
  • $500 for prescription hearing aids
  • $225 for eyeglasses and contacts
  • $200 for over-the-counter supplies ($50 per quarter)
Dental Services Preventive and basic dental services at no cost, including two dental cleanings and two exams per year ($1,200 total allowance)
Vision Services No-cost routine eye exam (up to 1 every year) with the freedom to choose from hundreds of participating providers and retailers, plus $225 to spend on eyewear via Flex Card
Hearing Services $10 copay for routine hearing exam (up to 1 every year), plus $500 to spend on prescription hearing aids via Flex Card
Fitness Benefit No-cost fitness center membership or home fitness kits
Over-the-Counter Supplies $200 ($50 per quarter) via Flex Card to spend at major retailers or to order online or by phone for home delivery
Online Primary Care $0 copay for 24/7 online medical visits through BlueCare
Member Wellness Rewards Up to $50 per year in gift cards from major retailers for completing approved wellness exams and/or screenings
24-hour Nurse Help Line Talk to a registered nurse at any time to help make the right choice in care based on symptoms

* For in-network services only, where applicable. Retailer restrictions may apply.

The Silver&Fit Program is provided by American Specialty Health Fitness Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a registered trademark of ASH and used with permission herein. All programs and services are not available in all areas.

2023 Blue Advantage (PPO) Plan 004 Documents:

The benefit information provided is a brief summary, not a complete description of benefits. Premiums and copayments/coinsurance amounts may change on January 1 of each year.
If you would like to speak with an agent or request a free kit, please call us toll free at 1-800-232-4967 (TTY 711) 7 days a week from 8 a.m. – 8 p.m.