Premium $0 MOOP  $3,400 IN ; $5,100 OON PCP $0 IN ;

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Premium$0Inpatient Hospital$400 (days 1-4)Emergency Care$90Urgent Care$45PCP$15Telehealth (PCP & Urgent Care) BlueCare On

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Premium$0Inpatient Hospital$495 (days 1-4)Emergency Care$90Urgent Care$65PCP$15Specialist$50PT, OT, SP$40OP Surgery$0 or $395 (i.e.

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Premium$19Inpatient Hospital$450 (days 1-4)Emergency Care$90Urgent Care$45PCP$10Specialist$45PT, OT, SP$40OP Surgery$0 or $325 (i.e.

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Premium $0 MOOP  $6,700 PCP $0 Specialist $45 Referrals Required No Inpatient

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