Health 2021 - GroupAccess - Alabama

Dental Blue(R) - Plans Tailored For Your Business.

2021 Health Plans | 2021 Dental Blue Plans

2022 Health Plans

Represents In-Network Benefits

2021 Rate Increase Justification

Reset Plans	Blue Choice® Platinum for Business	Blue Access® Gold for Business	Blue Secure Gold for Business	Blue Secure Silver for Business	Blue HSA Silver for Business	Blue Saver® Bronze for Business
Materials	View Coverage Summary (SBC) View Benefit Summary View Benefit Booklet	View Coverage Summary (SBC) View Benefit Summary View Benefit Booklet	View Coverage Summary (SBC) View Benefit Summary View Benefit Booklet	View Coverage Summary (SBC) View Benefit Summary View Benefit Booklet	View Coverage Summary (SBC) View Benefit Summary View Benefit Booklet	View Coverage Summary (SBC) View Benefit Summary View Benefit Booklet
Calendar Year Deductible SELF-ONLY FAMILY	$100 $200	$600 $1,200	$1,200 $2,400	$4,000 $8,000	$4,000 $8,000	$7,750 $15,500
Out-of-Pocket SELF-ONLY FAMILY Includes deductible, copays, and coinsurance for in-network services MORE	$4,000 $8,000	$6,000 $12,000	$6,750 $13,000	$8,550 $17,100	$6,000 $12,000	$7,750 $15,500
Office Visit Copay	$20 Primary Care/ $30 Specialist	$30 Primary Care/ $50 Specialist	$35 Primary Care/ $60 Specialist	$40 Primary Care/ $70 Specialist	Plan pays 80% after Deductible	$40 copay for 1st three illness related office visits; thereafter plan pays 100% after Deductible
Telephone and Online Video Consultation Available through Teladoc	$20 payment per consultation	$30 payment per consultation	$35 payment per consultation	$40 payment per consultation	Plan pays 0% after a $45 payment per consultation	$45 per consultation
Inpatient Hospital	Plan pays 100% after $150 daily copay days 1 - 5 for each admission	Lower Member Cost Share: Plan pays 100% after $250 daily copay days 1-5 for each admission Higher Member Cost Share: Plan pays 100% after $500 daily copay days 1-5 for each admission	Lower Member Cost Share: Plan pays 100% after $300 daily copay days 1-5 for each admission Higher Member Cost Share: Plan pays 100% after $600 daily copay days 1-5 for each admission	Lower Member Cost Share: Plan pays 100% after $450 daily copay days 1-5 for each admission Higher Member Cost Share: Plan pays 100% after $850 daily copay days 1-5 for each admission	Plan pays 80% after Deductible	Plan pays 100% after Deductible
Outpatient Surgery	Plan pays 100% after $150 hospital copay	Lower Member Cost Share: Plan pays 100% after $250 hospital copay Higher Member Cost Share: Plan pays 100% after $500 hospital copay	Lower Member Cost Share: Plan pays 100% after $300 hospital copay Higher Member Cost Share: Plan pays 100% after $600 hospital copay	Lower Member Cost Share: Plan pays 100% after $450 hospital copay Higher Member Cost Share: Plan pays 100% after $850 hospital copay	Plan pays 80% after Deductible	Plan pays 100% after Deductible
ER Visit	Plan pays 100% after $150 hospital copay	Plan pays 100% after $250 hospital copay	Plan pays 100% after $300 hospital copay	Plan pays 100% after $450 hospital copay	Plan pays 80% after Deductible	Plan pays 100% after Deductible
Prescription Drugs (per 30-day supply)	Tier 1 $10 copay Tier 2 $20 copay Tier 3 $35 copay Tier 4 $75 copay Tier 5 $100 copay Tier 6 $200 copay	Tier 1 $10 copay Tier 2 $20 copay Tier 3 $40 copay Tier 4 $80 copay Tier 5 $125 copay Tier 6 $250 copay	Tier 1 $10 copay Tier 2 $20 copay Tier 3 $50 copay Tier 4 $90 copay Tier 5 $200 copay Tier 6 $300 copay	Tier 1 $15 copay Tier 2 $30 copay Tier 3 $75 copay Tier 4 $100 copay Tier 5 $250 copay Tier 6 Plan pays 60%	Tier 1 - Tier 6 Plan pays 80% after Deductible	Tier 1 $20 copay Tier 2 $35 copay Tier 3 - Tier 6 Plan pays 100% after Deductible
Mail Order Pharmacy (90 day supply)	Tier 1 $25 copay Tier 2 $50 copay Tier 3 $87.50 copay Tier 4 $187.50 copay Tier 5 not covered Tier 6 not covered	Tier 1 $25 copay Tier 2 $50 copay Tier 3 $100 copay Tier 4 $200 copay Tier 5 not covered Tier 6 not covered	Tier 1 $25 copay Tier 2 $50 copay Tier 3 $125 copay Tier 4 $225 copay Tier 5 not covered Tier 6 not covered	Tier 1 $37.50 copay Tier 2 $75 copay Tier 3 $187.50 copay Tier 4 $250 copay Tier 5 not covered Tier 6 not covered	N/A	N/A
ValueONE Pharmacy Network	x	x	x	x	x	x
Source+Rx 2.0 Formulary	x	x	x
Source+Rx 1.0 formulary				x	x	x
Pediatric Vision	Plan pays 80% after Deductible	Plan pays 80% after Deductible	Plan pays 80% after Deductible	Plan pays 80% after Deductible	Plan pays 80% after Deductible	Plan pays 100% after Deductible
Pediatric Dental DIAGNOSTIC & PREVENTIVE BASIC SERVICES MAJOR SERVICES MEDICALLY NECESSARY ORTHODONTIA	Plan pays 100% Plan pays 80% Plan pays 50% after Deductible Plan pays 50% after Deductible	Plan pays 100% Plan pays 80% Plan pays 50% after Deductible Plan pays 50% after Deductible	Plan pays 100% Plan pays 80% Plan pays 50% after Deductible Plan pays 50% after Deductible	Plan pays 100% Plan pays 80% Plan pays 50% after Deductible Plan pays 50% after Deductible	Plan pays 100% after Deductible Plan pays 80% after Deductible Plan pays 50% after Deductible Plan pays 50% after Deductible	Plan pays 100% Plan pays 100% Plan pays 100% after Deductible Plan pays 100% after Deductible

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