Compare Plans

Silver Plan

Silver 6850

Plan BenefitsIn Network Only
Coinsurance

40%

Deductible (single/family)

$6,850/$13,700

Maximum Out Of Pocket (single/family)

$7,800/$15,600

Primary Care Physician Services

$25 copayment per visit

Doctors Care/Blue CareOnDemand

$25 copayment per visit

Maternity Care

$60 first visit

Specialist Visit

$60 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

40% after deductible

Outpatient Hospital Services

40% after deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Emergency Room

40% after deductible

Ambulance

40% after deductible

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

Tier 1: $25 retail/$50 mail order;
Tier 2: $25 retail/$50 mail order;
Tier 3: $45 retail/$90 mail order;
Tier 4: $80 retail/$160 mail order

Specialty Pharmaceuticals

Tier 5: $300 retail/$600 mail order;
Tier 6: $300 retail/$600 mail order

Durable Medical Equipment

40% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

40% after deductible. 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services.

Silver 7350

Plan BenefitsIn Network Only
Coinsurance

0%

Deductible (single/family)

$7,350/$14,700

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$40 copayment per visit

Doctors Care/Blue CareOnDemand

$40 copayment per visit

Maternity Care

$80 copayment first visit

Specialist Visit

$80 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible

Outpatient Hospital Services

Deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Emergency Room

Deductible

Ambulance

Deductible

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

Tier 5: $300 retail/$600 mail order;
Tier 6: $300 retail/$600 mail order

Durable Medical Equipment

Deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible. 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services.

Silver 6250

Plan BenefitsIn Network Only
Coinsurance

25%

Deductible (single/family)

$6,250/$12,500

Maximum Out Of Pocket (single/family)

$7,800/$15,600

Primary Care Physician Services

$20 copayment per visit

Doctors Care/Blue CareOnDemand

$20 copayment per visit

Maternity Care

$55 copayment first visit

Specialist Visit

$55 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

25% after deductible

Outpatient Hospital Services

25% after deductible

Emergency Room

25% after deductible

Ambulance

25% after deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

Tier 1: $20 retail/$40 mail order;
Tier 2: $20 retail/$40 mail order;
Tier 3: $40 retail/$80 mail order;
Tier 4: $90 retail/$180 mail order

Specialty Pharmaceuticals

Tier 5: $300 retail/$600 mail order;
Tier 6: $300 retail/$600 mail order

Durable Medical Equipment

25% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

25% after deductible. 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services.

Silver 2000

Plan BenefitsIn Network Only
Coinsurance

50%

Deductible (single/family)

$2,000/$4,000

Maximum Out Of Pocket (single/family)

$7,500/$15,000

Primary Care Physician Services

$35 copayment per visit

Doctors Care/Blue CareOnDemand

$35 copayment per visit

Maternity Care

$75 first visit

Specialist Visit

$75 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

$400 copayment, then 50% after deductible

Outpatient Hospital Services

50% after deductible

Emergency Room

$400 copayment, then 50% after deductible

Ambulance

50% after deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

Tier 1: $20 retail/$40 mail order;
Tier 2: $20 retail/$40 mail order;
Tier 3: 50% after deductible retail/50% after deductible mail order;
Tier 4: 50% after deductible retail/50% after deductible mail order

Specialty Pharmaceuticals

Tier 5: 50% after deductible retail/50% after deductible mail order;
Tier 6: 50% after deductible retail/50% after deductible mail order

Durable Medical Equipment

50% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

50% after deductible. 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services.

Silver 3200

Plan BenefitsIn Network Only
Coinsurance

50%

Deductible (single/family)

$3,200/$6,400

Maximum Out Of Pocket (single/family)

$7,900/$15,800

Primary Care Physician Services

$35 copayment per visit

Doctors Care/Blue CareOnDemand

$35

Maternity Care

$80 copayment first visit

Specialist Visit

$80 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

50% after deductible

Outpatient Hospital Services

50% after deductible

Emergency Room

$400, then 50% after deductible

Ambulance

50% after deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

Tier 1: $25 retail/$50 mail order;
Tier 2: $25 retail/$50 mail order;
Tier 3: $50 retail/$100 mail order;
Tier 4: $90 retail/$180 mail order

Specialty Pharmaceuticals

Tier 5: $300retail/$600 mail order;
Tier 6: $300 retail/$600 mail order

Durable Medical Equipment

50% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

50% after deductible; 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services.

Silver 3500

Plan BenefitsIn Network Only
Coinsurance

40%

Deductible (single/family)

$3,500/$7,000

Maximum Out Of Pocket (single/family)

$8,000/$16,000

Primary Care Physician Services

$40 copayment per visit

Doctors Care/Blue CareOnDemand

$40 copaymenet per visit

Maternity Care

$80 copayment first visit

Specialist Visit

$80 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

40% after deductible

Outpatient Hospital Services

40% after deductible

Emergency Room

$350 copayment, then 40% after deductible

Ambulance

40% after deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

Tier 1: $25 retail/$50 mail order;
Tier 2: $25 retail/$50 mail order;
Tier 3: $70 retail/$140 mail order;
Tier 4: $95 retail/$190 mail order

Specialty Pharmaceuticals

Tier 5: $300 retail/$600 mail order;
Tier 6: $300 retail/$600 mail order

Durable Medical Equipment

40% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

40% after deductible. 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services.

Silver 6100 HD

Plan BenefitsIn Network Only
Coinsurance

0%

Deductible (single/family)

$6,100/$12,200

Maximum Out Of Pocket (single/family)

$6,100/$12,200

Primary Care Physician Services

Deductible

Doctors Care/Blue CareOnDemand

Deductible

Maternity Care

Deductible

Specialist Visit

Deductible

Urgent Care

Deductible

Inpatient Hospital Services

Deductible

Outpatient Hospital Services

Deductible

Emergency Room

Deductible

Ambulance

Deductible

Freestanding Ambulatory Surgical Center

Deductible

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

Tier 5: Deductible retail/Deductible mail order;
Tier 6: Deductible retail/Deductible mail order

Durable Medical Equipment

Deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible. 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services.

Silver 5550

Plan BenefitsIn Network Only
Coinsurance

20%

Deductible (single/family)

$5,550/$11,100

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$45 copayment per visit

Doctors Care/Blue CareOnDemand

$45 copayment per visit

Maternity Care

$100 first visit

Specialist Visit

$100 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

$500 copayment, then 20% after deductible

Outpatient Hospital Services

20% after deductible

Emergency Room

$500 copayment, then 20% after deductible

Ambulance

20% after deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

Tier 1: $15 retail/$30 mail order;
Tier 2: $15 retail/$30 mail order;
Tier 3: $35 retail/$70 mail order;
Tier 4: 20% after deductible retail/20% after deductible mail order

Specialty Pharmaceuticals

Tier 5: 20% after deductible retail/20% after deductible mail order;
Tier 6: 20% after deductible retail/20% after deductible mail order

Durable Medical Equipment

20% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

20% after deductible; 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services.

Silver 4300 HD

Plan BenefitsIn Network Only
Coinsurance

0%

Deductible (single/family)

$4,300/$8,600

Maximum Out Of Pocket (single/family)

$4,300/$8,600

Primary Care Physician Services

Deductible

Doctors Care/Blue CareOnDemand

Deductible

Maternity Care

Deductible

Specialist Visit

Deductible

Urgent Care

Deductible

Inpatient Hospital Services

Deductible

Outpatient Hospital Services

Deductible

Emergency Room

Deductible

Ambulance

Deductible

Freestanding Ambulatory Surgical Center

Deductible

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

Tier 5: deductible retail/deductible mail order;
Tier 6: deductible retail/deductible mail order

Durable Medical Equipment

Deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible; 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services.

Silver 7000

Plan BenefitsIn Network Only
Coinsurance

0%

Deductible (single/family)

$7,000/$14,000

Maximum Out Of Pocket (single/family)

$7,000/$14,000

Primary Care Physician Services

$0 copayment per visit

Doctors Care/Blue CareOnDemand

$0 copayment per visit

Maternity Care

$50 first visit

Specialist Visit

$50 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

$500 copayment, then deductible

Outpatient Hospital Services

Deductible

Emergency Room

$500 copayment, then deductible

Ambulance

Deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

Tier 1: $25 retail/$50 mail order;
Tier 2: $25 retail/$50 mail order;
Tier 3: $45 retail/ $90 mail order;
Tier 4: Deductible retail/ Deductible mail order

Specialty Pharmaceuticals

Tier 5: deductible retail/deductible mail order;
Tier 6: deductible retail/deductible mail order

Durable Medical Equipment

Deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible; 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services.

Bronze Plan

Bronze 5550

Plan BenefitsIn Network Only
Coinsurance

35%

Deductible (single/family)

$5,550/$11,100

Maximum Out Of Pocket (single/family)

$8,550/$17,100

Primary Care Physician Services

$60

Doctors Care/Blue CareOnDemand

$60

Maternity Care

35% after deductible

Specialist Visit

35% after deductible

Urgent Care

$75

Inpatient Hospital Services

$500 copayment, then 35% after deductible

Outpatient Hospital Services

35% after deductible

Emergency Room

$500 copayment, then 35% after deductible

Ambulance

35% after deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

Tier 1: 35% after deductible retail/35% after deductible mail order;
Tier 2: 35% after deductible retail/35% after deductible mail order;
Tier 3: 35% after deductible retail/35% after deductible mail order;
Tier 4: 35% after deductible retail/35% after deductible mail order

Specialty Pharmaceuticals

Tier 5: 35% after deductible retail/35% after deductible mail order;
Tier 6: 35% after deductible retail/35% after deductible mail order

Durable Medical Equipment

35% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

35% after deductible. 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services and we will treat covered transplants the same as any other medical condition.

Bronze 6900 HD

Plan BenefitsIn Network Only
Coinsurance

0%

Deductible (single/family)

$6,900/$13,800

Maximum Out Of Pocket (single/family)

$6,900/$13,800

Primary Care Physician Services

Deductible

Doctors Care/Blue CareOnDemand

Deductible

Maternity Care

Deductible

Specialist Visit

Deductible

Urgent Care

Deductible

Inpatient Hospital Services

Deductible

Outpatient Hospital Services

Deductible

Emergency Room

Deductible

Ambulance

Deductible

Freestanding Ambulatory Surgical Center

Deductible

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

Tier 5: deductible retail/deductible mail order;
Tier 6: deductible retail/deductible mail order

Durable Medical Equipment

Deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible. 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services and we will treat covered transplants the same as any other medical condition.

Bronze 6500

Plan BenefitsIn Network Only
Coinsurance

20%

Deductible (single/family)

$6,500/$13,000

Maximum Out Of Pocket (single/family)

$8,550/$17,100

Primary Care Physician Services

$60 copayment per visit

Doctors Care/Blue CareOnDemand

$60 copayment per visit

Maternity Care

$100 copayment first visit

Specialist Visit

$100 copayment per visit

Urgent Care

$75 copayment per visit

Inpatient Hospital Services

$500 copayment, then 20% after deductible

Outpatient Hospital Services

$500 copayment, then 20% after deductible

Emergency Room

$500 copayment, then 20% after deductible

Ambulance

20% after deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

Tier 1: $40 retail/$80 mail order;
Tier 2: $40 retail/$80 mail order;
Tier 3: 20% after deductible retail/20% after deductible mail order;
Tier 4: 20% after deductible retail/20% after deductible mail order

Specialty Pharmaceuticals

Tier 5: 20% after deductible retail/20% after deductible mail order;
Tier 6: 20% after deductible retail/20% after deductible mail order

Durable Medical Equipment

20% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

20% after deductible. 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services.

Bronze 7300

Plan BenefitsIn Network Only
Coinsurance

50%

Deductible (single/family)

$7,300/$14,600

Maximum Out Of Pocket (single/family)

$8,550/$17,100

Primary Care Physician Services

$65 copayment per visit

Doctors Care/Blue CareOnDemand

$65 copayment per visit

Maternity Care

$100 first visit

Specialist Visit

$100 copayment per visit

Urgent Care

$75 copayment per visit

Inpatient Hospital Services

$500 copayment, then 50% after deductible

Outpatient Hospital Services

$500 copayment, then 50% after deductible

Emergency Room

$500 copayment, then 50% after deductible

Ambulance

50% after deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

Tier 1: $40 retail/$80 mail order;
Tier 2: $40 retail/$80 mail order;
Tier 3: 50% after deductible retail/50% after deductible mail order;
Tier 4: 50% after deductible retail/50% after deductible mail order

Specialty Pharmaceuticals

Tier 5: 50% after deductible retail/50% after deductible mail order;
Tier 6: 50% after deductible retail/50% after deductible mail order

Durable Medical Equipment

50% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

50% after deductible. 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services.

Bronze 8550

Plan BenefitsIn Network Only
Coinsurance

0%

Deductible (single/family)

$8,550/$17,100

Maximum Out Of Pocket (single/family)

$8,550/$17,100

Primary Care Physician Services

$70 copayment per visit

Doctors Care/Blue CareOnDemand

$70 copayment per visit

Maternity Care

$100 first visit

Specialist Visit

$100 copayment per visit

Urgent Care

$75 copayment per visit

Freestanding Ambulatory Surgical Center

$200 copayment per visit

Inpatient Hospital Services

Deductible

Outpatient Hospital Services

Deductible

Emergency Room

Deductible

Ambulance

Deductible

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

Tier 1: $40 retail/$80 mail order;
Tier 2: $40 retail/$80 mail order;
Tier 3: Deductible retail/Deductible mail order;
Tier 4: Deductible retail/Deductible mail order

Specialty Pharmaceuticals

Tier 5: Deductible retail/Deductible mail order;
Tier 6: $Deductible retail/Deductible mail order

Durable Medical Equipment

Deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible; 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services.

Catastrophic Plan

Catastrophic

Plan BenefitsIn Network Only
Coinsurance

0%

Deductible (single/family)

$8,550/$17,100

Maximum Out Of Pocket (single/family)

$8,550/$17,100

Primary Care Physician Services

$25 for first three visits; deductible thereafter

Doctors Care/Blue CareOnDemand

$25 for first three visits; deductible thereafter

Maternity Care

Deductible

Specialist Visit

Deductible

Urgent Care

Deductible

Inpatient Hospital Services

Deductible

Outpatient Hospital Services

Deductible

Emergency Room

Deductible

Ambulance

Deductible

Freestanding Ambulatory Surgical Center

Deductible

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

Tier 5: deductible retail/deductible mail order;
Tier 6: deductible retail/deductible mail order

Durable Medical Equipment

Deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible. 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice HealthPlan-participating facility must provide services.

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