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Blue Plan Schedule of Benefits 2026

Blue Plan	Tier 1 - ÍÃ×ÓÏÈÉú´«Ã½ÎÄ»¯×÷Æ· Health	Tier 2 - In-Network (Medical Mutual SuperMed in Ohio, CIGNA outside Ohio)	Tier 3 - Out-of-Network (may be balanced bill)
Aggregate Deductible	Ìý	Ìý	Ìý
Single	$1,700	$2,100	$2,600
Single+1 OR Family	$3,400	$4,200	$5,200
Coinsurance	95% after ded.	85% after ded.	70% after ded.
Maximum Out of Pocket	Ìý	Ìý	Ìý
Single	$2,200	$3,200	$4,200
Single+1 OR Family	$4,400	$6,400	$8,400
Deductible and Out of Pocket Satisfactions	Tier 1 ded./OOP satisfiesTier 1 and 2	Tier 2 ded./OOP satisfies Tier 1 and 2	Tier 3 ded./OOP satisfies Tier 1, 2, 3
Physician/Office Services	Ìý	Ìý	Ìý
Preventive Health Services	Covered in full, not subject to deductible	Covered in full, not subject to deductible	70% after ded.
Office Visit	95% after ded.	85% after ded.	70% after ded.
Specialist Visit	95% after ded.	85% after ded.	70% after ded.
Podiatry Services	95% after ded.	85% after ded.	70% after ded.
Routine Vision Exam	95% after ded.	85% after ded.	70% after ded.
OB/GYN Visits (Non-Preventive)	95% after ded.	85% after ded.	70% after ded.
Annual GYN Visit (Preventive)	Covered in full, not subject to deductible	Covered in full, not subject to deductible	70% after ded.
Chiropractic Services (35 visits per member per year)	95% after ded.	85% after ded.	70% after ded.
Infertility Services — does not apply to max out of pocket	70% after ded., up to $15,000 per calendar year	70% after ded., up to $15,000 per calendar year	Not covered
Diagnostics	Ìý	Ìý	Ìý
Diagnostic Test (X-ray, lab)	95% after ded.	85% after ded.	70% after ded.
Imaging (CT/PET scans, MRI’s) †PA	95% after ded.	85% after ded.	70% after ded.
Maternity Care	Ìý	Ìý	Ìý
Prenatal and Postnatal	N/A	Covered in full, not subject to deductible	70% after ded.
Delivery	N/A	85% after ded.	70% after ded.
Hospital Services	Ìý	Ìý	Ìý
Inpatient †PA	95% after ded.	85% after ded.	70% after ded.
Outpatient	95% after ded.	85% after ded.	70% after ded.
Emergency Room Facility	95% after ded.	85% after ded.	85% after ded.
Urgent Care	N/A	85% after ded.	70% after ded.
Durable Medical Equipment (subject to Medicare Part B) †PA	95% after ded.	85% after ded.	70% after ded.
Foot Orthotics (subject to Medicare Part B Guidelines) †PA	N/A	85% after ded.	70% after ded.
Prosthetic Devices †PA	N/A	85% after ded.	70% after ded.
Human Organ Transplant †PA	95% after ded.	85% after ded.	Not covered
Bariatric Treatment*	95% after ded.	N/A	N/A
Bariatric Surgery*	70% after ded.	N/A	N/A
Ambulance	Ìý	Ìý	Ìý
Emergency Use	N/A	85% after ded.	85% after ded.
Outpatient Surgical Facility Services	Ìý	Ìý	Ìý
Including Outpatient Surgery Facility Charge	95% after ded.	85% after ded.	70% after ded.
TherapyÌý Services	Ìý	Ìý	Ìý
Inpatient Rehabilitation †PA up to 60 days per member per calendar year	95% after ded.	85% after ded.	70% after ded.
Outpatient Physical/Occupational/Speech Therapy up to 35 visits per member, per calendar year (combined)	95% after ded.	85% after ded.	70% after ded.
Skilled Nursing Facility	Ìý	Ìý	Ìý
120 day limit per member, per calendar year †PA	95% after ded.	85% after ded.	70% after ded.
Hospice/Home Health Care	Ìý	Ìý	Ìý
In Lieu of Hospitalization †PA	N/A	85% after ded.	70% after ded.
Mental Health/Substance Abuse	Ìý	Ìý	Ìý
Office Visit, Specialist, Inpatient, Outpatient	Based on service type	Based on service type	Based on service type

*$50,000 lifetime maximum for bariatric services.

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†PA - Prior Authorization Required

Updated 10/1/2025