Blue Max 90/70 $1500
97176LA0340015
Gold
PPO
Blue Max 90/70 $1500 is a Gold PPO plan by Blue Cross and Blue Shield of Louisiana.
Locations
Blue Max 90/70 $1500 is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of Blue Max 90/70 $1500 97176LA0340015.
| Insurer: | Blue Cross and Blue Shield of Louisiana |
| Network Type: | PPO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 97176LA0340015 |
Cost-Sharing Overview
Blue Max 90/70 $1500 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Blue Max 90/70 $1500 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9200 per person | $18400 per group |
| Deductible: | $1500 per person | $4500 per group |
| Coinsurance: | 10.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Blue Max 90/70 $1500 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | $18400 per person | $36800 per group |
| Out-of-Network Deductible: | $3000 per person | $9000 per group |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $1,500 |
| Copayment: | $0 |
| Coinsurance: | $1,110 |
| Limit: | $60 |
| Deductible: | $1,500 |
| Copayment: | $0 |
| Coinsurance: | $320 |
| Limit: | $60 |
| Deductible: | $1,500 |
| Copayment: | $0 |
| Coinsurance: | $130 |
| Limit: | $0 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
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Plan Features
Blue Max 90/70 $1500 offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Blue Max 90/70 $1500 covers when you are out of the service area or out of the country.
| Out of Country Coverage: | Yes |
| Out of Country Coverage Description: | Emergency and non-emergency coverage subject to Blue Card Worldwide rules. |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | Coverage available for covered benefits |
| National Network: | Yes |
Additional Benefits and Cost-Sharing
Blue Max 90/70 $1500 includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | The Physician Office Copayment may be reduced or waived when services are rendered by a Provider participating in the Quality Blue Program (QB). QB Providers include family practitioners, general practitioners, pediatricians, internists, geriatricians, nurse practitioners, and physician assistants, but more Providers may contract to participate in the Quality Blue program. The Physician Office Copayment may also be reduced or waived when services are rendered by a Provider participating in the Affinity Health Group. |
| Specialist Visit Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | If you have a copayment plan, the Specialist copayment may be reduced or waived when services are rendered by an Affinity Health Group Provider. |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Exclusions include but not limited to: a. rhinoplasty; b. blepharoplasty services identified by CPT codes 15820, 15821, 15822, 15823; brow ptosis identified by CPT code 67900; or any revised or equivalent codes; c. gynecomastia; d. breast enlargement or reduction, except for breast reconstructive services as specifically provided in this Benefit Plan; e. implantation, removal and/or re-implantation of breast implants and services, illnesses, conditions, complications and/or treatment in relation to or as a result of breast implants; f. implantation, removal and/or re-implantation of penile prosthesis and services, illnesses, conditions, complications and/or treatment in relation to or as a result of penile prosthesis; g. diastasis recti; h. biofeedback; i. treatment related to erectile or sexual dysfunctions, low sexual desire disorder or other sexual inadequacies. j. Surgical and medical treatment for snoring in the absence of obstructive sleep apnea, including laser assisted uvulopalatoplasty (LAUP). k. Reversal of a voluntary sterilization procedure. Surgical services examples include but not limited to: 1. The Allowable Charge for Inpatient and Outpatient Surgery includes all pre-operative and postoperative medical visits. 2. Multiple Surgical Procedures – When Medically Necessary multiple procedures (concurrent, successive, or other multiple surgical procedures) are performed at the same surgical setting 3. Assistant Surgeon 4. General anesthesia services are covered when requested by the operating Physician and performed by a certified registered nurse anesthetist (CRNA) or Physician, other than the operating Physician or the assistant surgeon, for covered surgical services. Outpatient Medical and Surgical Services include: 1. Home, office, and other Outpatient visits for examination, diagnosis, and treatment of an illness or injury. Benefits for Outpatient medical services do not include separate payments for routine pre-operative and post-operative medical visits for Surgery or Pregnancy Care. 2. Services of an Ambulatory Surgical Center 3. Consultation (as defined in this Benefit Plan) |
| Hospice Services Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Not Covered | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Inpatient Private Duty Nursing Services are not covered. Plan limits coverage for Outpatient Private Duty Nursing Services to three hundred (300) hours per Benefit Period. |
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Home Health Care Services Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Home Health Care services provided to a Member in lieu of an Inpatient Hospital Admission are covered; must obtain authorization. |
| Emergency Room Services Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 10.00% Coinsurance after deductible | The ER copayment is waived if the visit results in an Inpatient Admission. |
| Emergency Transportation/Ambulance Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | No benefits are available if transportation is provided for the Member’s comfort or convenience, or when a hospital transports members between parts of its own campus. Emergency Transportation/ Ambulance Includes but not limited to: To or from the nearest Hospital (when medically necessary); Benefits for air ambulance servcies are available only if this type of ambulance service is requested by policing or medical authorities at the site in an emergency situation or if the member is in a location that cannot be reached for a ground ambulance; |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Inpatient Bed, Board and General Nursing Services include but not limited to: 1. Hospital room and board and general nursing services. 2. In a Special Care Unit for a critically ill Member requiring an intensive level of care. 3. In a Skilled Nursing Facility or Unit or while receiving skilled nursing services in a Hospital, for the maximum number of days per Benefit Period shown in the Schedule of Benefits. 4. In a Residential Treatment Center for Members with Mental Disorders and Alcohol and/or Drug Abuse Benefits. B. Other Hospital Services (Inpatient and Outpatient) 1. Use of operating, delivery, recovery and treatment rooms and equipment. 2. Drugs and medicines including take-home Prescription Drugs. 3. Blood transfusions, including the cost of whole blood, blood plasma and expanders, processing charges, administrative charges, equipment and supplies. 4. Anesthesia, anesthesia supplies and anesthesia services rendered by a Hospital employee. 5. Medical and surgical supplies, casts, and splints. 6. Diagnostic Services rendered by a Hospital employee. 7. Physical Therapy provided by a Hospital employee. 8. Psychological testing when ordered by the attending Physician and performed by an employee of the hospital. |
| Inpatient Physician and Surgical Services Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Surgical services examples include but not limited to: 1. The Allowable Charge for Inpatient and Outpatient Surgery includes all pre-operative and postoperative medical visits. 2. Multiple Surgical Procedures – When Medically Necessary multiple procedures (concurrent, successive, or other multiple surgical procedures) are performed at the same surgical setting 3. Assistant Surgeon 4. General anesthesia services are covered when requested by the operating Physician and performed by a certified registered nurse anesthetist (CRNA) or Physician, other than the operating Physician or the assistant surgeon, for covered surgical services. Inpatient Medical Services – Subject to provisions in the sections pertaining to Surgery and Pregnancy Care in this Benefit Plan, Inpatient Medical Services include: 1. Inpatient medical care visits 2. Concurrent Care 3. Consultation (as defined in this Benefit Plan) |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | Unless required for a Congenital Anomaly. | ||
| Skilled Nursing Facility Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Prenatal and Postnatal Care Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | The Member must pay applicable Copayment, Deductible Amount and/or Coinsurance. |
| Mental/Behavioral Health Outpatient Services Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Coverage for treatment of Mental Disorders does NOT include counseling services such as career counseling, marriage counseling, divorce counseling, parental counseling and job counseling. Education services and supplies including training or re-training for a vocation, except as specifically provided in this Benefit Plan for diagnosis, testing, or treatment for remedial reading and learning disabilities, including dyslexia. Office visits are covered same as primary care physician benefit. |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Substance Abuse Disorder Outpatient Services Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Office visits are covered same as primary care physician benefit. Covered Services will be only those, which are for treatment for abuse of alcohol, drugs or other chemicals, and the resultant physiological and/or psychological dependency, which develops with continued use. |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Generic Drugs Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 10.00% Coinsurance after deductible | Certain exclusion apply – Please see the contract book for a full list of pharmacy exclusions. Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer’s recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. All pharmacy plans have preventive drugs per USPSTF for $0. For 2-tier pharmacy plans, additional selected generic preventive care drugs in certain classes cost $0. For 3-tier and 4-tier pharmacy plans, additional selected drugs in certain classes used to treat selected chronic conditions cost $0. |
| Preferred Brand Drugs Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 10.00% Coinsurance after deductible | Certain exclusion apply – Please see the contract book for a full list of pharmacy exclusions. Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer’s recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. Note that for 3-tier and 4-tier plans, when a Brand-Name Drug is dispensed and a generic equivalent exists, Members must pay theTier 1 Drug Copayment amount, plus the difference in cost between the Brand-Name Drug dispensed and its generic equivalent. The Copayment for the Brand-Name Drug will not apply. The Member?s payment will apply to the Out-of-Pocket Amount. For 2-tier plans, the plan participant must pay the generic drug coinsurance, plus the difference in cost between the brand-name drug dispensed and its generic equivalent. |
| Non-Preferred Brand Drugs Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 10.00% Coinsurance after deductible | Certain exclusion apply – Please see the contract book for a full list of pharmacy exclusions. Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer’s recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. Note that for 3-tier and 4-tier plans, when a Brand-Name Drug is dispensed and a generic equivalent exists, Members must pay the Tier 1 Drug Copayment amount, plus the difference in cost between the Brand-Name Drug dispensed and its generic equivalent. The Copayment for the Brand-Name Drug will not apply. The Member?s payment will apply to the Out-of-Pocket Amount. For 2-tier plans, the plan participant must pay the generic drug coinsurance, plus the difference in cost between the brand-name drug dispensed and its generic equivalent. |
| Specialty Drugs Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 10.00% Coinsurance after deductible | Certain exclusion apply – Please see the contract book for a full list of pharmacy exclusions. Specialty drugs are distributed throughout all tiers including 2-tier, 3-tier, and 4-tier plans and the member is responsible to pay the applicable deductible/copay/coinsurance for that tier. Retail day supply limits (typically 30-day supply) apply. In addition, quantity per dispensing (QPD) limits/allowances are placed on certain specialty medications and are based on the manufacturer’s recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. |
| Outpatient Rehabilitation Services Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Other exclusions include but not limited to: Visual therapy lifestyle/habit changing clinics and/or programs; recreational therapy; primarily to enhance athletic abilities; and/or inpatient pain rehabilitation and inpatient pain control programs Rehabilitative Benefits are available for services provided on an Outpatient basis when the services are rendered by a licensed Provider. |
| Habilitation Services Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Other exclusions include but not limited to: Visual therapy; lifestyle/habit changing clinics and/or programs; recreational therapy; primarily to enhance athletic abilities; and/or inpatient pain rehabilitation and inpatient pain control programs An Inpatient rehabilitation Admission must begin within seventy-two (72) hours following the discharge from an Inpatient Hospital Admission for the same or similar condition. Day Rehabilitation Programs for Rehabilitative Care may be Authorized in place of Inpatient stays for rehabilitation. Day Rehabilitation Programs must begin within seventy-two (72) hours following discharge from an Inpatient Admission for the same or similar condition. Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings |
| Chiropractic Care Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Durable Medical Equipment Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Exclusions are but not limited to: hairpieces, wigs, hair growth, and/or hair implants; Personal comfort, personal hygiene and convenience items including, but not limited to, air conditioners, humidifiers, personal fitness equipment, or alterations to a Member?s home or vehicle. Limitations in connection with Durable Medical Equipment are but not limited to: (1) There is no coverage during rental of Durable Medical Equipment for repair, adjustment, or replacement of components and accessories necessary for the effective functioning and maintenance of covered equipment as this is the responsibility of the Durable Medical Equipment supplier. (2) There is no coverage for equipment where a commonly available supply or appliance can substitute to effectively serve the same purpose. (3) There is no coverage for the repair or replacement of equipment lost or damaged due to neglect or misuse. (4) Reasonable quantity limits on Durable Medical Equipment items and supplies will be determined by Us. 2. Orthotic Devices, Prosthetic Appliances and Devices (non-limb) and Prosthetic Appliances and Devices and Prosthetic Services of the Limb Limitations: a. There is no coverage for fitting, or adjustments as this is, included in the Allowable Charge b. Repair or replacement is covered only within a reasonable time period from the date of purchase subject to the expected lifetime of the device. We will determine this time period. Repair or replacement of the device will not be covered when provided under warranty. c. When Orthotic Devices are approved by Us, Benefits for standard devices will be provided toward any deluxe device. (1) Deluxe devices or deluxe features and functionalities of devices are those: (a) that do not serve a medical purpose; (b) that are not required to complete daily living activities; (c) that are solely for the Member?s comfort or convenience; or (d) that are not determined by Us to be Medically Necessary. (2) Regardless of Claims of Medical Necessity, deluxe devices and deluxe features and functionalities of devices that are not approved by Us are not covered d. No Orthotics Benefits are available for supportive devices for the foot, except when used in the treatment of diabetic foot disease. |
| Hearing Aids Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 100.00% | 1.0 Item(s) per 3 Years Certain exclusion apply – Please see the contract book. Benefits are available for hearing aids for covered Members when obtained from a Network Provider or another Provider approved by Us. This Benefit is limited to one hearing aid, per ear, in a thirty-six (36) month period. The hearing aid must be fitted and dispensed by a licensed audiologist or licensed hearing aid specialist or hearing aid dealer following the medical clearance of a Physician and an audiological evaluation medically appropriate to the patient. 1 hearing aid per ear every 3 years; hearing aids or for examinations for the prescribing or fitting of hearing aids. Benefits are available for hearing aids for covered Members when obtained from a Network Provider or another Provider approved by Us. |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Preventive Care/Screening/Immunization Covered | No Charge No Charge | Not Applicable 30.00% | Any services not included in the following Non-Grandfathered Preventive Care Services Brochure link is excluded: https://www.bcbsla.com/preventive Use the following Non-Grandfathered Preventive Care Services Brochure link for a complete list ? limitation and ages may vary: https://www.bcbsla.com/preventive Listed below is a sample of the Preventative/Screening/Immunization Benefits. Please refer to the member contract for more comprehensive list. EXAMINATIONS AND TESTING: Routine Wellness Physical Examination?Certain routine wellness diagnostic tests ordered by Your Physician are covered. Well Baby Care; Prostate Cancer Screening; Colorectal Cancer Screening; IMMUNIZATION: All state mandated immunizations including the complete basic immunization series as defined by the state health officer and required for school entry for children up to age six (6) SCREENING AND COUNSELING: Abdominal Aortic Aneurysm Screening; Alcohol Misuse Screening and Counseling; Blood Pressure Screening; Cholesterol Screening; Depression Screening; Type 2 Diabetes Screening; Diet Counseling; HIV Screening; Obesity Screening and Counseling; Sexually Transmitted Infection Counseling; Tobacco Use Screening; Syphilis Screening; COVERED SERVICES FOR WOMEN: Counseling for – BRCA genetic testing and breast cancer chemoprevention; Routine Gynecologist / Obstetrician Visits; Mammography Examination; Osteoporosis Screening; Routine Pap Smear; Screening ?Chlamydia Infection and Gonorrhea; COVERED SERVICES FOR PREGNANT WOMEN: Anemia Screening; Bacteriuria Screening; Breast Feeding Intervention; Folic Acid Supplements; Hepatitis B Screening; Rh Incompatibility Screening; COVERED SERVICES FOR CHILDREN: Alcohol and Drug Use Assessments; Autism Screening; Behavioral Assessments; Cervical Dysplasia Screening; Congenital Hypothyroidism Screening; Developmental Screening; Dyslipidemia Screening |
| Routine Foot Care Not Covered | Benefits are excluded for palliative or cosmetic care or treatment of the foot; supportive devices of the foot; and treatment of flat feet, except for Medically Necessary Surgery. Benefits are excluded for routine foot care, except as specifically provided. | ||
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | No Charge No Charge | Not Applicable 100.00% | 1.0 Visit(s) per Year |
| Eye Glasses for Children Covered | No Charge No Charge | Not Applicable 100.00% | 1.0 Item(s) per Year Pediatric selection of eyeglass frames or if a member chooses a Non-Selection frame he/she will pay the difference in retail price between the Selection and the Non-Selection frame. Prescription Contact Lenses may be selected in lieu of eyeglasses from the Pediatric Selection of Contact Lenses up to a maximum of 2 pairs of disposable or 2 pairs of planned replacement Contact Lenses. If a member chooses Non-Selection Contact Lenses he/she will pay the difference in retail price between the Selection and the Non-Selection contact lenses. Evaluation, fitting and follow-up care up to 1 visit are included when Prescription Contact Lenses are selected in lieu of eyeglasses. |
| Dental Check-Up for Children Covered | No Charge No Charge | No Charge No Charge | 1.0 Visit(s) per 6 Months Limitations may apply. Subject to Dental deductible, if applicable. |
| Rehabilitative Speech Therapy Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Rehabilitative Care Benefits will be available for Services provided on a Inpatient or Outpatient basis, including services for Occupational Therapy, Physical Therapy, Speech/Language Pathology Therapy, and/or Chiropractic Services. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Rehabilitative Care Benefits will be available for Services provided on a Inpatient or Outpatient basis, including services for Occupational Therapy, Physical Therapy, Speech/Language Pathology Therapy, and/or Chiropractic Services. |
| Well Baby Visits and Care Covered | No Charge No Charge | Not Applicable 30.00% | |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Basic Dental Care – Child Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Limitations, including dollar limits, may apply. Subject to Dental deductible, if applicable. Limitations may apply. |
| Orthodontia – Child Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Limitations, including dollar limits, may apply. Subject to Dental deductible, if applicable. Limitations may apply. |
| Major Dental Care – Child Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Limitations, including dollar limits, may apply. Subject to Dental deductible, if applicable. Limitations may apply. |
| Basic Dental Care – Adult Not Covered | |||
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Not Covered | |||
| Abortion for Which Public Funding is Prohibited Not Covered | |||
| Transplant Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 100.00% | Exclusions are but not limited to: any costs of donating an organ or tissue for transplant when a Member is a donor; the transplant of any non-human organ or tissue; or bone marrow transplants and stem cell rescue (autologous and allogeneic) are not covered, except as provided in this Benefit Plan. If any organ, tissue or bone marrow is sold rather than donated to a Member, the purchase price of such organ, tissue or bone marrow is not covered. Benefit available in network only. |
| Accidental Dental Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Dental Care and Treatment including Surgery and dental appliances required to correct Accidental Injuries of the jaws, cheeks, lips, tongue, roof or floor of mouth, and of sound natural teeth. (For the purposes of this section, sound natural teeth include those which are capped, crowned or attached by way of a crown or cap to a bridge. Sound natural teeth may have fillings or a root canal.) |
| Dialysis Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Allergy Testing Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Chemotherapy Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Radiation Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Diabetes Education Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Coverage is available for self-management training and education, dietician visits and for the equipment and necessary available for self-management training and education, dietician visits and for the equipment and necessary supplies for the training, if prescribed by the Member?s Physician. Coverage is available for the equipment, supplies, and Outpatient self-treatment training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin using diabetes if prescribed by the Member?s Physician. The program must be determined to be medically necessary by a physician and provided by a licensed health care professional and shall comply with the National standard for diabetes self-management education program as developed by the ADA. |
| Prosthetic Devices Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Benefits will be available for the purchase of Prosthetic Appliances and Devices and Prosthetic Services of the limbs that we Authorize. Repair or replacement of the Prosthetic Appliance or Device is covered only within a reasonable time period from the date of purchase subject to the expected lifetime of the appliance. We will determine this time period. Prosthetic Appliances and Devices of the limb must be prescribed by a licensed Physician and provided by a facility accredited by the American Board for Certification in Orthotics Prosthetics and Pedorthics (ABC) or by the Board for Orthotist/Prosthetist Certification (BOC). |
| Infusion Therapy Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Treatment for Temporomandibular Joint Disorders Not Covered | |||
| Nutritional Counseling Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Covered under Dietician visits. |
| Reconstructive Surgery Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | 1. Under the Women?s Health and Cancer Rights Act, a Member who is receiving Benefits in connection with a mastectomy and elects breast reconstruction will also receive Benefits for the following Covered Services: a. All stages of reconstruction of the breast on which a partial or full unilateral mastectomy has been performed or reconstruction of both breasts if a bilateral mastectomy has been performed; b. Surgery and reconstruction of the other breast to produce a symmetrical appearance, including but not limited to liposuction performed for transfer to a reconstructed breast or to repair a donor site deformity, tattooing the areola of the breast, surgical adjustments of the non-mastectomized breast, unforeseen medical Complications which may require additional reconstruction in the future; c. prostheses; and d. treatment of physical Complications of all stages of the mastectomy, including lymphedemas. |
| Gender Affirming Care Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Non-Emergency Care When Traveling Outside the U.S. Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Clinical Trials Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | The following services are not covered: a. Non-healthcare services provided as part of the clinical trial; b. Costs for managing research data associated with the clinical trial; c. Investigational drugs or devices; and/or d. Services, treatment or supplies not otherwise covered under this Benefit Plan. |
| Diabetes Care Management Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Diabetes coverage is available for the equipment, supplies, and Outpatient self-treatment training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin using diabetes if prescribed by a Member?s Physician. |
| Inherited Metabolic Disorder – PKU Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Exclusions are but not limited to: food or food supplements, formulas and medical foods, including those used for gastric tube feedings. Low Protein Food Products shall not include natural foods that are naturally low in protein. Benefits for Low Protein Food Products are limited to the treatment of the following diseases: Phenylketonuria (PKU); Maple Syrup Urine Disease (MSUD); Methylmalonic Acidemia (MMA); Isovaleric Acidemia (IVA); Propionic Acidemia; Glutaric Acidemia; Urea Cycle Defects; Tyrosinemia. |
| Dental Anesthesia Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Prescription Drugs Other Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Some drugs covered under medical benefit. |
| Congenital Anomaly, including Cleft Lip/Palate Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | Cleft Lip and Cleft Palate Services include but not limited to: 1. Oral and facial Surgery, surgical management, and follow-up care. 2. Prosthetic treatment, such as obturators, speech appliances, and feeding appliances. 3. Orthodontic treatment and management. 4. Preventive and restorative dentistry to ensure good health and adequate dental structures for orthodontic treatment or prosthetic management or therapy. 5. Speech-language evaluation and therapy. 6. Audiological assessments and amplification devices. 7. Otolaryngology treatment and management. 8. Psychological assessment and counseling. 9. Genetic assessment and counseling for patient and parents. Includes benefits for secondary conditions and treatment attributable to the primary medical condition of either cleft lip and cleft palate. |
| Attention Deficit Disorder Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible |
Free Preventive Services
There is no copayment or coinsurance for any of the following Blue Max 90/70 $1500 preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Blue Max 90/70 $1500 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
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