BluePreferred PPO Standard Gold 2000

40308VA0240011
Gold
PPO

BluePreferred PPO Standard Gold 2000 is a Gold PPO plan by CareFirst BlueCross BlueShield.

IMPORTANT: You are viewing the 2023 version of BluePreferred PPO Standard Gold 2000 40308VA0240011. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

BluePreferred PPO Standard Gold 2000 is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of BluePreferred PPO Standard Gold 2000 40308VA0240011.
Insurer: CareFirst BlueCross BlueShield
Network Type: PPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 40308VA0240011

Cost-Sharing Overview

BluePreferred PPO Standard Gold 2000 offers the following cost-sharing.

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

BluePreferred PPO Standard Gold 2000 offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management
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 BluePreferred PPO Standard Gold 2000 covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: All Covered Services
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: All Covered Services
National Network: Yes

Additional Benefits and Cost-Sharing

BluePreferred PPO Standard Gold 2000 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
$30.00 40.00% Coinsurance after deductible Including doctor visits in the home and online visits.
Specialist Visit
Covered
$60.00 40.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 40.00% Coinsurance after deductible Includes Retail Health Clinics (walk-ins).
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye.
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye.
Hospice Services
Covered
No Charge No Charge 40.00% Coinsurance after deductible Short-term Inpatient Hospital care when needed in periods of crisis or as respite care. Skilled nursing services, home health aide services, and homemaker/custodial care services given by or under the supervision of a registered nurse. Social services and counseling services from a licensed social worker. Nutritional support such as intravenous feeding and feeding tubes. Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed therapist. Pharmaceuticals, medical equipment, and supplies needed for pain management and the palliative care of your condition, including oxygen and related respiratory therapy supplies. Bereavement (grief) services, including a review of the needs of the bereaved family and the development of a care plan to meet those needs, both before and after the Member?s death. Bereavement services are available to surviving Members of the immediate family for one year after the Member?s death. Immediate family means your spouse, children, stepchildren, parents, brothers and sisters.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
No Charge No Charge 40.00% Coinsurance after deductible16 Hours per Benefit Period
Routine Eye Exam (Adult)
Covered
No Charge No Charge 100.00%1 Exam(s) per Benefit Period For out-of-network services, Member pays expenses in excess of the Vision Allowed Benefit.
Urgent Care Centers or Facilities
Covered
$45.00 $45.00 Includes X-ray services; Care for broken bones; Tests such as flu, urinalysis, allergy test, pregnancy test, rapid strep; Lab services; Stitches for simple cuts; and Draining an abscess.
Home Health Care Services
Covered
No Charge No Charge 40.00% Coinsurance after deductible100 Visit(s) per Benefit Period Visit limit does not apply to home infusion therapy or home dialysis. The Home Care visit limit will apply instead of the Therapy Services limits for physical, occupational, speech therapy, or cardiac rehabilitation for therapy in the home. Benefit includes intermittent skilled nursing services by an R.N. or L.P.N.; Medical/social services; Diagnostic services; Nutritional guidance; Training of the patient and/or family/caregiver; Home health aide services; Therapy Services; Medical supplies; Durable medical equipment.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible Benefits are available in a Hospital Emergency Room or an independent, free-standing emergency facility for services and supplies to treat the onset of symptoms for a medical emergency.
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible Includes medically necessary transportation to the nearest appropriate hospital for a medical emergency, or between hospitals or other approved facilities. Includes ground, water, fixed wing and rotary air transportation. Benefits also include medically necessary treatment of a sickness or injury by medical professionals from an ambulance service, even if you are not taken to a facility. Benefits are only available for air ambulance when it is not appropriate to use a ground or water ambulance.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Benefits for room, board, and nursing services include: a room with two or more beds; a private room when medically necessary for isolation and no isolation facilities are available; a room in an approved special care unit; meals, special diets; general nursing services; operating, childbirth, and treatment rooms and equipment; prescribed drugs; anesthesia, anesthesia supplies and services given by the hospital or other provider; medical and surgical dressings and supplies, casts, and splints; blood and blood products; diagnostic services. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility.
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes medical care visits; intensive medical care when medically necessary; treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for surgery; treatment by two or more Doctors during one Hospital stay when the nature or severity of your health problem calls for the skill of separate Doctors; a personal bedside exam by another Doctor when asked for by your Doctor; surgery and general anesthesia; professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when medically necessary; medically necessary pre-operative and post-operative care. Medical benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is medically necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye.
Bariatric Surgery
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Benefits are available for gastric bypass Surgery or other such methods recognized by the National Institutes of Health as effective for the long-term reversal of Morbid Obesity. Surgical treatment for obesity, except surgery for Morbid Obesity, is excluded.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible100 Days per Admission Includes room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies. Your Plan will cover the private room charge when medically necessary.
Prenatal and Postnatal Care
Covered
No Charge No Charge 40.00% Coinsurance after deductible Includes prenatal and postnatal services for the mother; postnatal services for the baby, including hemoglobinopathies screening; gonorrhea prophylactic medication; hypothyroidism screening, PKY screening and Rh incompatibility testing.
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes services needed during a normal or complicated pregnancy and for services needed for a miscarriage. Covered maternity services include: pregnancy testing; professional and facility services for childbirth including use of the delivery room and care for normal deliveries, in a facility or the home including the services of an appropriately licensed nurse midwife; anesthesia services to provide partial or complete loss of sensation before delivery; routine nursery care for the newborn during the mother?s normal hospital stay, including circumcision of a covered male dependent; allowed fetal screenings, which are genetic or chromosomal tests of the fetus. Hospital stay for childbirth for mother and newborn may not be limited to less than 48 hours after vaginal birth or less than 96 hours after a cesarean section, unless the mother and attending provider request it.
Mental/Behavioral Health Outpatient Services
Covered
$30.00 40.00% Coinsurance after deductible Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law.
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes services in a hospital or any facility required to be covered by state law. Inpatient benefits include individual psychotherapy, group psychotherapy, psychological testing, counseling with family members to assist with the patient?s diagnosis and treatment, convulsive therapy, detoxification, and rehabilitation.
Substance Abuse Disorder Outpatient Services
Covered
$30.00 40.00% Coinsurance after deductible Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law.
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes services in a hospital or any facility required to be covered by state law. Inpatient benefits include individual psychotherapy, group psychotherapy, psychological testing, counseling with family members to assist with the patient?s diagnosis and treatment, convulsive therapy, detoxification, and rehabilitation.
Generic Drugs
Covered
$15.00 $15.00 Covers prescription legend drugs from either a Retail Pharmacy or the PBM?s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the ‘Preventive Care’ benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug not exceed $50 for a 30-day supply, and $100 for a 90-day supply. If a provider prescribes a Non-Preferred Brand Name Drug, and the Member selects the Non-Preferred Brand Name Drug when a Generic Drug is available, the Member shall pay the applicable Copayment as stated in this Schedule of Benefits plus the difference between the price of the Non-Preferred Brand Name Drug and the Generic Drug. A Member will be allowed to obtain a Non-Preferred Brand Name Drug in place of an available Generic Drug and pay only the Non-Preferred Brand Name Drug Copayment when Medically Necessary, as determined by CareFirst.
Preferred Brand Drugs
Covered
$30.00 $30.00 Covers prescription legend drugs from either a Retail Pharmacy or the PBM?s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the ‘Preventive Care’ benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug not exceed $50 for a 30-day supply, and $100 for a 90-day supply. If a provider prescribes a Non-Preferred Brand Name Drug, and the Member selects the Non-Preferred Brand Name Drug when a Generic Drug is available, the Member shall pay the applicable Copayment as stated in this Schedule of Benefits plus the difference between the price of the Non-Preferred Brand Name Drug and the Generic Drug. A Member will be allowed to obtain a Non-Preferred Brand Name Drug in place of an available Generic Drug and pay only the Non-Preferred Brand Name Drug Copayment when Medically Necessary, as determined by CareFirst.
Non-Preferred Brand Drugs
Covered
$60.00 $60.00 Covers prescription legend drugs from either a Retail Pharmacy or the PBM?s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the ‘Preventive Care’ benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug not exceed $50 for a 30-day supply, and $100 for a 90-day supply. If a provider prescribes a Non-Preferred Brand Name Drug, and the Member selects the Non-Preferred Brand Name Drug when a Generic Drug is available, the Member shall pay the applicable Copayment as stated in this Schedule of Benefits plus the difference between the price of the Non-Preferred Brand Name Drug and the Generic Drug. A Member will be allowed to obtain a Non-Preferred Brand Name Drug in place of an available Generic Drug and pay only the Non-Preferred Brand Name Drug Copayment when Medically Necessary, as determined by CareFirst.
Specialty Drugs
Covered
$250.00 100.00% Covers prescription legend drugs from either a Retail Pharmacy or the PBM?s Home Delivery Pharmacy; self-administered injectable drugs; specialty drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the ‘Preventive Care’ benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug not exceed $50 for a 30-day supply, and $100 for a 90-day supply.
Outpatient Rehabilitation Services
Covered
$30.00 40.00% Coinsurance after deductible30 Visit(s) per Benefit Period Benefits are based on the setting in which covered services are received. See individual therapy limits.Limited to 30 visits for speech therapy and 30 visits combined for occupational therapy and physical therapy. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.
Habilitation Services
Covered
$30.00 40.00% Coinsurance after deductible30 Visit(s) per Benefit Period Benefits that help you keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn?t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, medical devices, and other services for people with disabilities in a variety of inpatient and/or outpatient settings. See individual therapy limits. Limited to 30 visits for speech therapy and 30 visits combined for occupational therapy and physical therapy. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.
Chiropractic Care
Covered
$30.00 40.00% Coinsurance after deductible30 Visit(s) per Benefit Period Includes therapy to treat problems of the bones, joints, joints of the spine, the nervous system, and the back, and osteopathic therapy which focuses on the joints and surrounding muscles, tendons and ligaments. Limited to 30 visits per benefit period ( limit applies separately for habilitative and rehabilitate services)
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes Medical Devices, Orthotics, Medical and Surgical Supplies. Benefits include equipment and devices (e.g., crutches and customized equipment, Hospital beds and wheelchairs, oxygen concentrator, ventilator, and negative pressure, wound therapy devices). Coverage for ongoing rental of equipment may be limited to the cost of purchasing the equipment. Benefits include repair and replacement costs as well as supplies and equipment needed for the use of the equipment or device, for example, a battery for a powered wheelchair. Oxygen and equipment for its administration are also covered services. Benefits are also available for cochlear implants. Benefits are available for certain types of orthotics (braces, boots, and splints). Covered Services include the initial purchase, fitting, and repair of a custom made rigid or semi-rigid supportive device used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body, or which limits or stops motion of a weak or diseased body part. Also, includes coverage for devices and supplies, such as APAP, CPAP, BPAP and oral devices for sleep treatment, subject to medical necessity.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine; and advanced imaging, including CT scan, CTA scan, Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiography (MRA); Magnetic Resonance Spectroscopy (MRS); Nuclear Cardiology; PET scans; PET/CT Fusion scans; QTC Bone Densitometry; Diagnostic CT Colonography; Single photon emission computed tomography (SPCECT) scans.
Preventive Care/Screening/Immunization
Covered
No Charge No ChargeNo Charge after deductible No Charge after deductible Covers: (1) Services with an ‘A’ or ‘B’ rating from the United States Preventive Services Task Force; (2) Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; (3) Preventive care and screenings for infants, children and adolescents as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening); (4) Preventive care and screening for women as listed in the guidelines supported by the Health Resources and Services Administration; and (5) Counseling services related to nutrition, and to smoking and tobacco use cessation. Prescription drugs that help you stop smoking or reduce your dependence on tobacco products are also covered preventive services. Smoking cessation products and over the counter nicotine replacement products (limited to nicotine patches and gum) are covered when obtained with a prescription. Additionally, state law requires coverage for routine screening mammograms and routine prostate specific antigen testing and digital rectal exams.
Routine Foot Care
Not Covered
Acupuncture
Covered
$60.00 40.00% Coinsurance after deductible30 Visit(s) per Benefit Period
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge No Charge 100.00%1 Exam(s) per Benefit Period The Member Payment will be Expenses in excess of the Vision Allowed Benefit for Out of Network/ Non-Contracting Vison Provider. Includes complete eye exam with dilation, as needed to check all aspects of vision, including the structure of the eyes and how well they work together.
Eye Glasses for Children
Covered
No Charge No Charge 100.00%1 Item(s) per Benefit Period The Member Payment will be Expenses in excess of the Vision Allowed Benefit for Out of Network/ Non-Contracting Vison Provider. Includes a choice of eyeglass lenses with factory scratch coating or contact lenses in one benefit period. Covered eyeglass lenses include standard plastic (CR39) lenses up to 55mm in: Single vision; Bifocal; Trifocal (FT 25-28); and Progressive. Members choose from a limited frame selection. Coverage for contact lenses includes elective or non-elective contact lenses. Non-elective contact lenses are covered only for the following medical conditions: Keratoconus when your vision is not correctable to 20/40 in either or both eyes using standard spectacle lenses; High Ametropia exceeding -12D or +9D in spherical equivalent; Anisometropia of 3D or more; when your vision can be corrected three lines of improvement on the visual acuity chart when compared to best corrected standard spectacle lenses.
Dental Check-Up for Children
Covered
No Charge No Charge 20.00%1 Treatment(s) per 6 Months Includes coverage for D1110, D1120, D1203, D1204, D1206, and D1208.
Rehabilitative Speech Therapy
Covered
$30.00 40.00% Coinsurance after deductible30 Visit(s) per Benefit Period Includes services to identify, assess, and treat speech, language, and swallowing disorders in children and adults. Therapy will develop or treat communication or swallowing skills to correct a speech impairment. Limit does not apply when received as part of hospice benefit, early intervention benefit, or for the treatment of autism spectrum disorders. Limited to 30 visits per benefit period ( limit applies separately for habilitative and rehabilitate services)
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 40.00% Coinsurance after deductible30 Visit(s) per Benefit Period Includes treatment to restore a physically disabled person?s ability to do activities of daily living, such as walking, eating, drinking, dressing, using the toilet, moving from a wheelchair to a bed, bathing, and therapy for tasks needed for the person?s job. Also, includes the treatment by physical means to ease pain, restore health, and to avoid disability after an illness, injury, or loss of an arm or a leg by means of hydrotherapy, heat, physical agents, bio-mechanical and neuro-physiological principles and devices. Limit is combined for physical and occupational therapy. Limit applies separately to habilitative and rehabilitative services. Limit does not apply when received as part of hospice benefit, early intervention benefit, or for the treatment of autism spectrum disorders.
Well Baby Visits and Care
Covered
No Charge No ChargeNo Charge No Charge Includes immunizations for children recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening).
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes benefits for tests or procedures to find or check a condition when specific symptoms exist, as well as benefits for interpretation of diagnostic tests such as imaging, and cardiology. Tests must be ordered by a Provider and include diagnostic services ordered before a surgery or Hospital admission. Benefits include the following services: x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine.
Basic Dental Care – Child
Covered
20.00% Coinsurance after deductible 40.00% Coinsurance after deductible Benefit limitations may apply to individual services. $25 in-network deductible for pediatric dental, and a $50 out of network deductible for standard plans and no deductible for NA $0 Plans.
Orthodontia – Child
Covered
50.00% 65.00%1 Treatment(s) per Lifetime Limit applies to one comprehensive orthodontic treatment of the adolescent dentition. The limitation of once per lifetime for medically necessary orthodontia.
Major Dental Care – Child
Covered
20.00% Coinsurance after deductible 40.00% Coinsurance after deductible Benefit limitations may apply to individual services. $25 in-network deductible for pediatric dental, and a $50 out of network deductible for standard plans and no deductible for NA $0 Plans.
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Transplant
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes coverage for medically necessary human organ, tissue, and stem cell/bone marrow transplants and infusions including necessary acquisition procedures, mobilization, harvest and storage. It also includes medically necessary myeloablative or reduced intensity preparative chemotherapy, radiation therapy, or a combination of these therapies. When a human organ transplant is provided from a living donor to a covered member, both the recipient and the donor may receive benefits.
Accidental Dental
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible Includes dental work, to include oral/surgical correction needed to treat injuries to the jaw, sound natural teeth, mouth or face as a result of an accident. Dental appliances required to diagnose or treat an accidental injury to the teeth, and the repair of dental appliances damaged as a result of accidental injury to the jaw, mouth or face, are also covered. Treatment must begin within 12 months of the injury, or as soon after that as possible to be a covered service.
Dialysis
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes services for acute renal failure and chronic (end-stage) renal disease, including hemodialysis, home intermittent peritoneal dialysis (IPD), home continuous cycling peritoneal dialysis (CCPD), and home continuous ambulatory peritoneal dialysis (CAPD). Dialysis treatments can be rendered in an outpatient dialysis Facility, doctor?s office, or home dialysis and training for the covered person and the person who will help with home self-dialysis.
Allergy Testing
Covered
$60.00 40.00% Coinsurance after deductible Includes benefits for medically necessary allergy testing and treatment, including allergy serum and allergy shots.
Chemotherapy
Covered
$60.00 40.00% Coinsurance after deductible
Radiation
Covered
$60.00 40.00% Coinsurance after deductible Includes treatment (tele therapy, brachytherapy and intraoperative radiation, photon or high-energy particle sources), materials and supplies needed, administration, and treatment planning.
Diabetes Education
Covered
$60.00 40.00% Coinsurance after deductible Includes education for diabetes care for all diabetics, including outpatient self-management training and education performed in-person; medical nutrition therapy, when provided by a certified, licensed, or registered health care professional. Diabetic education may be received from pharmacies that are authorized to perform this service.
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device. In additional, components for artificial limbs are covered. Components are the materials and equipment needed to ensure the comfort and functioning of the prosthetic device. Covered services may include: 1) Artificial limbs and components (the materials and equipment needed to ensure the comfort and functioning of the prosthetic device); 2) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Women?s Health and Cancer Rights Act. 3) Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to ostomy care. 4) Restoration prosthesis (composite facial prosthesis) 5) Wigs needed after cancer treatment (limited to one wig per benefit period).
Infusion Therapy
Covered
$20.00 40.00% Coinsurance after deductible Includes nursing, durable medical equipment and drug services that are delivered and administered to you through an I.V. in your home. Also includes Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain care and chemotherapy. May include injections (intra-muscular, subcutaneous, continuous subcutaneous). Also covers prescription drugs when they are administered to you as part of a doctor?s visit, home care visit, or at an outpatient Facility.
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes services to treat temporomandibular and craniomandibular disorders, such as removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. Dental benchmark plan covers occlusal orthotic devices for temporomandibular pain, dysfunction or associated musculature.
Nutritional Counseling
Covered
No Charge No ChargeNo Charge after deductible No Charge after deductible
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Includes reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Also includes surgery performed to restore symmetry after a mastectomy. Reconstructive services needed as a result of an earlier treatment are covered only if the first treatment would have been a covered service. Hospital admissions for covered radical or modified radical mastectomy for the treatment of breast cancer shall be approved for a period of no less than 48 hours. Hospital admissions for a covered total or partial mastectomy with lymph node dissection for the treatment of breast cancer shall be approved for a period of no less than 24 hours.
Gender Affirming Care

Free Preventive Services

There is no copayment or coinsurance for any of the following BluePreferred PPO Standard Gold 2000 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.

Additional Resources

Below are additional resources for BluePreferred PPO Standard Gold 2000 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
Ready to sign up for BluePreferred PPO Standard Gold 2000?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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