This plan exclusively covers you for in-network doctors and facilities and gives you access to Blue High Performance Network (HPN) providers in certain geographic locations based on your zip code. Blue HPN providers are selected based on delivery of quality, affordable care offering savings to Affiliate employees in exchange for a smaller provider network and the lowest paycheck deduction.  Because this is a copay plan, you’ll usually pay a fixed amount when you see in-network providers, and the plan will pay for the rest. Except in the case of an emergency, you’ll pay the full price for any out-of-network care.

Provider network Access to Blue HPN providers in certain geographic locations based on your zip code.
Primary Care Physician (PCP) to manage care Not required
Referrals needed to see a specialist Not required
Calendar Year Deductible
$5,000 per individual/$10,000 per family1
Health Savings Account (HSA) No
Coinsurance (You Pay) After Meeting Deductible In-network Only: 20%
Calendar Year Out-of-Pocket Maximum
$7,000 per individual/$14,000 per family
Preventive Care
In-network Only: Covered in full (calendar year deductible waived)
Office Visit (You Pay) PCP: $20 copay. Specialist: $75 copay
In-network Only: 20%2
Pharmacy Retail
(30-day supply)5
Network pharmacy: specified preventive drugs—100% covered3; generic—$10 copay2; brand formulary—$25 copay2; brand non-formulary—$40 copay2; specialty drugs-20%2,4 up to $125
Pharmacy Mail Services
(up to 90-day supply)
Network pharmacy: specified preventive drugs—100% covered3; generic—$20 copay2; brand formulary—$50 copay2; brand non-formulary—$80 copay2
  1. The family deductible must be met before any person receives benefits.
  2. After calendar year deductible.
  3. Calendar year deductible waived.
  4. May be available at Cerpass retail pharmacy or Pharmacy Mail Service if authorized. Note that any specialty drug discounts through copay cards or coupons will not apply towards the calendar year deductible our out-of-pocket maximum.
  5. A $10 copay will be added to the cost for any prescriptions filled at Walgreens.