Health 2022 - GroupAccess - Alabama

Plans Tailored For Your Business.

2022 Health Plans | 2022 Dental Blue Plans | 2022 Vision Blue^SM Plans

Represents In-Network Benefits

2022 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	$7,850 $15,700
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	$7,850 $15,700
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 $55 payment per consultation	$45 payment 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
Prescription Drugs (per 30-day supply)	Covered Insulin Cost Share Cap - A maximum $99 cost share will be implemented for covered insulin products for each 30-day supply. For HSA-Qualified HDHPs* when a covered insulin product qualifies as preventative care, the cost share cap applies whether or not deductible has been met. When a covered insulin product does not qualify as preventative care, the cost share cap shall not apply until deductible has been met.
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
Mail Order Pharmacy (90 day supply)	*Covered Insulin Cost Share Cap - A maximum $99 cost share will be implemented for covered insulin products for each 30-day supply.
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