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Silver Plan

Silver 1500

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$1,500/$3,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,100/$14,200
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$15 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$15 copayment per visit; deductible, then 50%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$15 copayment per visit; deductible, then 50%
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 50%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 50%
Emergency Room Emergency Room Emergency services you get in an emergency room.	$250, then deductible, then 50%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 50%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $15 retail/$30 mail order; Tier 2: $15 retail/$30 mail order; Tier 3: 50% retail/ 50% mail order; Tier 4: 50% retail/ 50% mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: $300 copayment, deductible, then 50% retail/$600 copayment, deductible, then 50% mail order; Tier 6: $300 copayment, deductible, then 50% retail/$600 copayment, deductible, then 50% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 50%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 50%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 1501

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$1,500/$3,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,500/$15,000
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$40 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$80 first visit; deductible, then 50%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$80 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 50%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 50%
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible, then 50%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 50%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $20 retail/$40 mail order; Tier 2: $20 retail/$40 mail order; Tier 3: $60 retail/ $120 mail order; Tier 4: $80 retail/ $160 mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: Deductible, then 50% retail/Deductible, then 50% mail order; Tier 6: Deductible, then 50% retail/Deductible, then 50% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 50%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 50%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 2000

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$2,000/$4,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,350/$14,700
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$0 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	Deductible, then 50%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	Deductible, then 50%
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 50%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 50%
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible, then 50%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 50%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $0 retail/$0 mail order; Tier 2: $0 retail/$0 mail order; Tier 3: Deductible, then 50% retail/Deductible, then 50% mail order; Tier 4: Deductible, then 50% retail/Deductible, then 50% mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: Deductible, then 50% retail/Deductible, then 50% mail order; Tier 6: Deductible, then 50% retail/Deductible, then 50% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 50%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 50%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 2502

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$2,500/$5,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,000/$14,000
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$25 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$50 payment first visit, then deductible, then 30%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$50 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	$250 per stay, then deductible, then 30%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 30%
Emergency Room Emergency Room Emergency services you get in an emergency room.	$250, then deductible, then 30%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 30%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $10 retail/$20 mail order; Tier 2: $10 retail/$20 mail order; Tier 3: Deductible, then 30% retail/Deductible, then 30% mail order; Tier 4: Deductible, then 30% retail/Deductible, then 30% mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: Deductible, then 30% retail/Deductible, then 30% mail order; Tier 6: Deductible, then 30% retail/Deductible, then 30% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 30%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 30%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 2503

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$2,500/$5,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,350/$14,700
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$0 copayment for first two visits, then deductible, then 50%
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	Deductible, then 50%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	Deductible, then 50%
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment for first two visits, then deductible, then 50%
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 50%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 50%
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible, then 50%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 50%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $25 retail/$50 mail order; Tier 2: $25 retail/$50 mail order; Tier 3: Deductible, then 50% retail/ Deductible, then 50% mail order; Tier 4: Deductible, then 50% retail/ Deductible, then 50% mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: Deductible, then 50% retail/Deductible, then 50% mail order; Tier 6: Deductible, then 50% retail/Deductible, then 50% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 50%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 50%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 3000

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$3,000/$6,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,350/$14,700
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$20 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$50 copayment first visit, then deductible, then 50%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$50 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	$300, then deductible, then 50%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 50%
Emergency Room Emergency Room Emergency services you get in an emergency room.	$300, then deductible, then 50%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 50%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $10 retail/$20 mail order; Tier 2: $10 retail/$20 mail order; Tier 3: $40 retail/$80 mail order; Tier 4: $80 retail/$160 mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: $300, then 50% retail/$600, then 50% mail order; Tier 6: $300, then 50% retail/$600, then 50% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 50%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 50%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 3001

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$3,000/$6,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,350/$14,700
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$30 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$80 copayment first visit, then deductible, then 35%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$80 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 35%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 35%
Emergency Room Emergency Room Emergency services you get in an emergency room.	$300 copayment, then deductible, then 35%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 35%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $20 retail/$40 mail order; Tier 2: $20 retail/$40 mail order; Tier 3: $50 retail/$100 mail order; Tier 4: $75 retail/$150 mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: 35% retail/35% mail order; Tier 6: 35% retail/35% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 35%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 35%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 3500

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$3,500/$7,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,350/$14,700
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$0 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$60 copayment first visit, then deductible, then 30%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$60 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 30%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 30%
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible, then 30%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 30%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $0 retail/$0 mail order; Tier 2: $0 retail/$0 mail order; Tier 3: Deductible, then 30% retail/ Deductible, then 30% mail order; Tier 4: Deductible, then 30% retail/ Deductible, then 30% mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: Deductible, then 30% retail/Deductible, then 30% mail order; Tier 6: Deductible, then 30% retail/ Deductible, then 30% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 30%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 30%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 3501

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$3,500/$7,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,500/$15,000
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$0 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$60 first visit; deductible, then 40%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$60 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 40%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 40%
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible, then 40%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 40%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $0 retail/$0 mail order; Tier 2: $0 retail/$0 mail order; Tier 3: Deductible, then 40% retail/Deductible, then 40% mail order; Tier 4: Deductible, then 40% retail/Deductible, then 40% mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: deductible, then 40% retail/deductible, then 40% mail order; Tier 6: deductible, then 40% retail/deductible, then 40% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 40%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 40%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 4000

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$4,000/$8,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$6,600/$13,200
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$15 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$40 copayment first visit, then deductible, then 30%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$40 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	$300, then deductible, then 30%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 30%
Emergency Room Emergency Room Emergency services you get in an emergency room.	$300 copayment, then deductible, then 30%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 30%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $15 retail/$30 mail order; Tier 2: $15 retail/$30 mail order; Tier 3: $50 retail/$100 mail order; Tier 4: Deductible, then 30% retail/Deductible, then 30% mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: Deductible, then 30% retail/Deductible, then 30% mail order; Tier 6: Deductible, then 30% retail/Deductible, then 30% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 30%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 30%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 4200

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$4,200/$8,400
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$4,200/$8,400
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	Deductible
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	Deductible
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	Deductible
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	Deductible
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible
Ambulance Ambulance Emergency medical transportation.	Deductible
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	Deductible
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: deductible retail/deductible mail order; Tier 2: deductible retail/deductible mail order; Tier 3: deductible retail/deductible mail order; Tier 4: deductible retail/deductible mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: deductible retail/deductible mail order; Tier 6: deductible retail/deductible mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 4500 HD

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$4,500/$9,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$4,500/$9,000
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	Deductible
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	Deductible
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	Deductible
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	Deductible
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible
Ambulance Ambulance Emergency medical transportation.	Deductible
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	Deductible
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: Deductible retail/Deductible mail order; Tier 2: Deductible retail/Deductible mail order; Tier 3: Deductible retail/deductible mail order; Tier 4: Deductible/Deductible mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: Deductible retail/Deductible mail order; Tier 6: Deductible retail/Deductible mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 5001

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$5,000/$10,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,350/$14,700
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$35 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$75 copayment first visit, then deductible, then 30%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$75 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 30%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 30%
Emergency Room Emergency Room Emergency services you get in an emergency room.	$300 copayment, then deductible, then 30%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 30%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $10 retail/$20 mail order; Tier 2: $10 retail/$20 mail order; Tier 3: $30 retail/$60 mail order; Tier 4: $75 retail/$150 mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: Deductible, then 30% retail/Deductible, then 30% mail order; Tier 6: Deductible, then 30% retail/Deductible, then 30% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 30%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 30%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 5004HD

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$5,000/$10,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$5,000/$10,000
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	Deductible
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	Deductible
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	Deductible
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	Deductible
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	Deductible
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible
Ambulance Ambulance Emergency medical transportation.	Deductible
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: Deductible retail/Deductible mail order; Tier 2:Deductible retail/Deductible mail order; Tier 3: Deductible retail/Deductible mail order; Tier 4: Deductible retail/Deductible mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: Deductible retail/Deductible mail order; Tier 6: Deductible retail/Deductible mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 6002

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$6,000/$12,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,350/$14,700
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$0 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$35 copayment first visit, then deductible, then 20%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$35 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	$300, then deductible, then 20%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 20%
Emergency Room Emergency Room Emergency services you get in an emergency room.	$300, then deductible, then 20%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 20%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $10 retail/$20 mail order; Tier 2: $10 retail/$20 mail order; Tier 3: $30 retail/$60 mail order; Tier 4: $75 retail/$150 mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: $300 retail/$600 mail order; Tier 6: $300 retail/$600 mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 20%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 20%; 15 combined visits per benefit year
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 6250

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$6,250/$12,500
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,350/$14,700
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$0 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$35 copayment first visit, then deductible, then 25%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$35 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 25%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 25%
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible, then 25%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 25%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $10 retail/$20 mail order; Tier 2: $10 retail/$20 mail order; Tier 3: $30 retail/$60 mail order; Tier 4: $75 retail/$150 mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: $300 retail/$600 mail order; Tier 6: $300 retail/$600 mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 25%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 25%; 15 combined visits per benefit year
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 6251

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$6,250/$12,500
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,750/$15,500
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$0 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$35 copayment first visit, then deductible, then 25%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$35 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 25%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 25%
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible, then 25%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 25%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $10 retail/$20 mail order; Tier 2: $10 retail/$20 mail order; Tier 3: $30 retail/$60 mail order; Tier 4: $75 retail/$150 mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: $300 retail/$600 mail order; Tier 6: $300 retail/$600 mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 25%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 25%; 15 combined visits per benefit year
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 6900

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$6,900/$13,800
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,350/$14,700
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$0
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$35 first visit, then deductible, then 40%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$35 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 40%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 40%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible, then 40%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 40%
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $5 retail/$10 mail order; Tier 2: $5 retail/$10 mail order; Tier 3: $30 retail/$60 mail order; Tier 4: $90 retail/$180 mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: Deductible, then 40% retail/Deductible, then 40% mail order; Tier 6: Deductible, then 40% retail/Deductible, then 40% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 40%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 40%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 7350

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$7,350/$14,700
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,350/$14,700
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$25 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$60 copayment first visit, then deductible
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$60 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible
Ambulance Ambulance Emergency medical transportation.	Deductible
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $10 retail/$20 mail order; Tier 2: $10 retail/$20 mail order; Tier 3: $30 retail/$60 mail order; Tier 4: Deductible retail/Deductible mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: Deductible retail/Deductible mail order; Tier 6: Deductible retail/Deductible mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Silver 7750

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$7,750/$15,500
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,750/$15,500
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$25 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$60 copayment first visit, then deductible
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$60 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible
Ambulance Ambulance Emergency medical transportation.	Deductible
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $10 retail/$20 mail order; Tier 2: $10 retail/$20 mail order; Tier 3: $30 retail/ $60 mail order; Tier 4: Deductible retail/ Deductible mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: deductible retail/deductible mail order; Tier 6: deductible retail/deductible mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Bronze Plan

Bronze 5500

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$5,500/$11,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$6,600/$13,200
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	Deductible, then 50%
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	Deductible, then 50%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	Deductible, then 50%
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	Deductible, then 50%
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 50%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 50%
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible, then 50%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 50%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: Deductible, then 50% retail/Deductible, then 50% mail order; Tier 2: Deductible, then 50% retail/Deductible, then 50% mail order; Tier 3: deductible, then 50% retail/Deductible, then 50% mail order; Tier 4: Deductible, then 50% retail/Deductible, then 50% mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: Deductible, then 50% retail/Deductible, then 50% mail order; Tier 6: Deductible, then 50% retail/Deductible, then 50% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 50%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 50%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services and we will treat covered transplants the same as any other medical condition.

Bronze 5501

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$5,500/$11,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,900/$15,800
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	Deductible, then 50%
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	Deductible, then 50%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	Deductible, then 50%
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	Deductible, then 50%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	Deductible, then 50%
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 50%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 50%
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible, then 50%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 50%
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: Deductible, then 50% retail/Deductible, then 50% mail order; Tier 2: Deductible, then 50% retail/Deductible, then 50% mail order; Tier 3: deductible, then 50% retail/Deductible, then 50% mail order; Tier 4: Deductible, then 50% retail/Deductible, then 50% mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: deductible, then 50% retail/deductible, then 50% mail order; Tier 6: deductible, then 50% retail/deductible, then 50% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 50%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 50%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Bronze 6000HD

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$6,000/$12,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$6,000/$12,000
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	Deductible
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	Deductible
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	Deductible
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	Deductible
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible
Ambulance Ambulance Emergency medical transportation.	Deductible
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	Deductible
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: deductible retail/deductible mail order; Tier 2: deductible retail/deductible mail order; Tier 3: deductible retail/deductible mail order; Tier 4: deductible retail/deductible mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: deductible retail/deductible mail order; Tier 6: deductible retail/deductible mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services and we will treat covered transplants the same as any other medical condition.

Bronze 6350HD

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$6,350/$12,700
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$6,350/$12,700
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	Deductible
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	Deductible
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	Deductible
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	Deductible
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible
Ambulance Ambulance Emergency medical transportation.	Deductible
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	Deductible
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: deductible retail/deductible mail order; Tier 2: deductible retail/deductible mail order; Tier 3: deductible retail/deductible mail order; Tier 4: deductible retail/deductible mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: deductible retail/deductible mail order; Tier 6: deductible retail/deductible mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services and we will treat covered transplants the same as any other medical condition.

Bronze 6500

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$6,500/$13,000
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$6,850/$13,700
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	Deductible, then 50%
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	Deductible, then 50%
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	Deductible, then 50%
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	Deductible, then 50%
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible, then 50%
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible, then 50%
Emergency Room Emergency Room Emergency services you get in an emergency room.	$300, then deductible, then 50%
Ambulance Ambulance Emergency medical transportation.	Deductible, then 50%
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: deductible, then 50% retail/deductible, then 50% mail order; Tier 2: deductible, then 50% retail/deductible, then 50% mail order; Tier 3: deductible, then 50% retail/deductible, then 50% mail order; Tier 4: deductible, then 50% retail/deductible, then 50% mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: deductible, then 50% retail/deductible, then 50% mail order; Tier 6: deductible, then 50% retail/deductible, then 50% mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible, then 50%
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible, then 50%; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Bronze 7150

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$7,150/$14,300
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,150/$14,300
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$45 copayment
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$90 first visit, deductible.
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$90 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible
Ambulance Ambulance Emergency medical transportation.	Deductible
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: deductible retail/deductible mail order; Tier 2: deductible retail/deductible mail order; Tier 3: deductible retail/deductible mail order; Tier 4: deductible retail/deductible mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: deductible retail/deductible mail order; Tier 6: deductible retail/deductible mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Bronze 7350

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$7,350/$14,700
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,350/$14,700
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$45 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$90 first visit, deductible
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$90 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible
Ambulance Ambulance Emergency medical transportation.	Deductible
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 per visit
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $30 retail/$60 mail order; Tier 2: $30 retail/$60 mail order; Tier 3: Deductible retail/Deductible mail order; Tier 4: Deductible retail/Deductible mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: Deductible retail/Deductible mail order; Tier 6: Deductible retail/Deductible mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Bronze 7900

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$7,900/$15,800
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,900/$15,800
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	Deductible
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	Deductible
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	Deductible
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	Deductible
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	Deductible
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible
Ambulance Ambulance Emergency medical transportation.	Deductible
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: deductible, then 50% retail/deductible, then 50% mail order; Tier 2: deductible, then 50% retail/deductible, then 50% mail order; Tier 3: deductible, then 50% retail/deductible, then 50% mail order; Tier 4: deductible, then 50% retail/deductible, then 50% mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: deductible retail/deductible mail order; Tier 6: deductible retail/deductible mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Bronze 7901

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$7,900/$15,800
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,900/$15,800
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$50 copayment per visit
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	$100 first visit, deductible
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	$100 copayment per visit
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	$50 copayment per visit
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	$200 copayment per visit
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible
Ambulance Ambulance Emergency medical transportation.	Deductible
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit.
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: $35 retail/$70 mail order; Tier 2: $35 retail/$70 mail order; Tier 3: $60 retail/$120 mail order; Tier 4: $75 retail/$150 mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: $300 retail/$600 mail order; Tier 6: $300 retail/$600 mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible; 15 combined visits per benefit year.
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Catastrophic Plan

Catastrophic

Plan Benefits	In Network Only
Deductible (single/family) Deductible (single/family) The amount you must pay for covered services before your health plan starts to pay. For example, your plan has a $500 deductible. You must pay the first $500 of allowable charges for covered services before your plan starts to pay benefits. Your health plan may pay some benefits before you meet your deductible. For example, your plan may pay some preventive services at 100 percent even if you have not met your deductible.	$7,900/$15,800
Maximum Out Of Pocket (single/family) Maximum Out Of Pocket (single/family) The MOOP is the most you pay during a policy period (usually one year) before BlueChoice HealthPlan starts to pay 100 percent for covered essential health benefits in-network providers provide. This limit must include deductibles, coinsurance, copayments and/or similar charges. It also includes any other expenditure that is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.	$7,900/$15,800
Primary Care Physician Services Primary Care Physician Services A physician (M.D.-Medical Doctor or D.O.-Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services. This includes providers in family practice, internal medicine and pediatrics, and nurse practitioners.	$25 for first three visits; deductible thereafter
Maternity Care (prenatal and postnatal) Maternity Care (prenatal and postnatal) Pre- and postnatal care, including the hospitalization and related professional services and routine nursery care and/or routine well-baby care.	Deductible
Specialist Visit Specialist Visit A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.	Deductible
Urgent Care Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.	Deductible
Inpatient Hospital Services Inpatient Hospital Services Treatment at a hospital that requires the individual to stay there.	Deductible
Outpatient Hospital Services Outpatient Hospital Services Treatment at a hospital that does not require the individual to stay there.	Deductible
Emergency Room Emergency Room Emergency services you get in an emergency room.	Deductible
Ambulance Ambulance Emergency medical transportation.	Deductible
Freestanding Ambulatory Surgical Center Freestanding Ambulatory Surgical Center A facility that is licensed for Outpatient Surgery only and doesn't provide overnight accommodations or around-the-clock care. The care must be provided under the supervision of a Physician. It also must provide nursing services by or under the supervision of an on duty registered nurse (RN). The facility must not be an office or clinic for the private practice of a Physician.	Deductible
Mental Health and Substance Abuse Mental Health and Substance Abuse Conditions defined, described or classified as psychiatric disorders or conditions in the latest publication of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders.	Covered as any other medical benefit
Gynecologist Exam (two exams per benefit year) Gynecologist Exam (two exams per benefit year) Full scope of services provided in the care of or related to the female reproductive system and breasts. Pap smears are the examination of the tissues of the cervix or the uterus for the purposes of detecting cancer.	$0
Routine Screening Mammogram Routine Screening Mammogram A radiological examination of the breast for purposes of detecting breast cancer.	$0
Routine Screening Colonoscopy Routine Screening Colonoscopy An examination that uses a long, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.	$0
Prescription Drugs Prescription Drugs Drugs and medications that, by law, require a prescription. We also cover syringes for diabetes. Tier 0: These drugs are considered preventive medications under the ACA and we cover them at no cost to you. Tier 1: Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket. Tier 2: Drugs on this tier are usually generic drugs. They will typically cost less than brand drugs. Tier 3: Drugs on this tier are usually preferred brand drugs. They typically cost less than other brand drugs. Tier 4: Drugs on this tier are usually non-preferred brand drugs. They typically cost more than other brand drugs and may have generic equivalents.	Tier 0: $0 retail/$0 mail order; Tier 1: deductible retail/deductible mail order; Tier 2: deductible retail/deductible mail order; Tier 3: deductible retail/deductible mail order; Tier 4: deductible retail/deductible mail order
Specialty Pharmaceuticals Specialty Pharmaceuticals Medications that treat a complex clinical condition with complex delivery of care and distribution requirements. They include, but are not limited to, infusible specialty drugs for chronic disease; injectable and self-injectable specialty drugs for acute and chronic diseases; and specialty oral drugs. Tier 5: Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically very expensive. Tier 6: Drugs on this tier are usually specialty drugs that are used to treat complex conditions. They are typically the most expensive drugs available.	Tier 5: deductible retail/deductible mail order; Tier 6: deductible retail/deductible mail order
Durable Medical Equipment Durable Medical Equipment Equipment and supplies a health care provider orders for everyday or extended use. Coverage for durable medical equipment may include oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.	Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation Services that help a person improve skills and functioning that have been lost or impaired due to an illness or injury. These services may include physical, occupational and speech therapy services in a variety of inpatient and/or outpatient settings. A licensed physical, occupational or speech therapist must provide the service. Habilitation: services that help a person keep, learn or improve skills and functioning. Examples include therapy for a child who isn't walking or talking at the expected age.	Deductible; 15 combined visits per benefit year
Transplants Transplants Medical and surgical services a member receives for human organ and/or tissue transplants, such as single/double kidney; pancreas and kidney; heart; single/double lung; liver; pancreas; heart and single/double lung; and bone marrow transplants.	A BlueChoice HealthPlan-participating facility must provide services. We will treat covered transplants the same as any other medical condition.

Not sure what you'll pay?

Silver Plan

Silver 1500

Silver 1501

Silver 2000

Silver 2502

Silver 2503

Silver 3000

Silver 3001

Silver 3500

Silver 3501

Silver 4000

Silver 4200

Silver 4500 HD

Silver 5001

Silver 5004HD

Silver 6002

Silver 6250

Silver 6251

Silver 6900

Silver 7350

Silver 7750

Bronze Plan

Bronze 5500

Bronze 5501

Bronze 6000HD

Bronze 6350HD

Bronze 6500

Bronze 7150

Bronze 7350

Bronze 7900

Bronze 7901

Catastrophic Plan

Catastrophic