This plan has in-network and out-of-network coverage for most services. The out-of-network annual deductible and out-of-pocket maximum are double the in-network amount. The amounts listed below apply for in-network services only.

Blue Elect Plus HMO breakdown
Blue Elect Plus
Self-Referral Plan Options
Gold $1,000
Annual deductible
(individual / family)
$1,000 / $2,000
Coinsurance Percentage 20%
Embedded
Coinsurance Maximum

(individual / family)
$3,500 / $7,000
Out-of-pocket maximum
(individual / family)
$7,350 / $14,700
PCP office visit copay
$20
Preferred generic pharmacy copay
$10