Compare Plans

Silver Plan

Silver 1500

Plan BenefitsIn Network Only
Deductible (single/family)

$1,500/$3,000

Maximum Out Of Pocket (single/family)

$7,100/$14,200

Primary Care Physician Services

$15 copayment per visit

Maternity Care (prenatal and postnatal)

$15 copayment per visit; deductible, then 50%

Specialist Visit

$15 copayment per visit; deductible, then 50%

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible, then 50%

Outpatient Hospital Services

Deductible, then 50%

Emergency Room

$250, then deductible, then 50%

Ambulance

Deductible, then 50%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 50%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 50%; 15 combined visits per benefit year.

Transplants

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

Silver 1501

Plan BenefitsIn Network Only
Deductible (single/family)

$1,500/$3,000

Maximum Out Of Pocket (single/family)

$7,500/$15,000

Primary Care Physician Services

$40 copayment per visit

Maternity Care (prenatal and postnatal)

$80 first visit; deductible, then 50%

Specialist Visit

$80 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible, then 50%

Outpatient Hospital Services

Deductible, then 50%

Emergency Room

Deductible, then 50%

Ambulance

Deductible, then 50%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 50%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 50%; 15 combined visits per benefit year.

Transplants

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

Silver 2000

Plan BenefitsIn Network Only
Deductible (single/family)

$2,000/$4,000

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$0 copayment per visit

Maternity Care (prenatal and postnatal)

Deductible, then 50%

Specialist Visit

Deductible, then 50%

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible, then 50%

Outpatient Hospital Services

Deductible, then 50%

Emergency Room

Deductible, then 50%

Ambulance

Deductible, then 50%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 50%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 50%; 15 combined visits per benefit year.

Transplants

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

Silver 2502

Plan BenefitsIn Network Only
Deductible (single/family)

$2,500/$5,000

Maximum Out Of Pocket (single/family)

$7,000/$14,000

Primary Care Physician Services

$25 copayment per visit

Maternity Care (prenatal and postnatal)

$50 payment first visit, then deductible, then 30%

Specialist Visit

$50 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

$250 per stay, then deductible, then 30%

Outpatient Hospital Services

Deductible, then 30%

Emergency Room

$250, then deductible, then 30%

Ambulance

Deductible, then 30%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 30%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 30%; 15 combined visits per benefit year.

Transplants

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

Silver 2503

Plan BenefitsIn Network Only
Deductible (single/family)

$2,500/$5,000

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$0 copayment for first two visits, then deductible, then 50%

Maternity Care (prenatal and postnatal)

Deductible, then 50%

Specialist Visit

Deductible, then 50%

Urgent Care

$50 copayment for first two visits, then deductible, then 50%

Inpatient Hospital Services

Deductible, then 50%

Outpatient Hospital Services

Deductible, then 50%

Emergency Room

Deductible, then 50%

Ambulance

Deductible, then 50%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 50%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 50%; 15 combined visits per benefit year.

Transplants

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

Silver 3000

Plan BenefitsIn Network Only
Deductible (single/family)

$3,000/$6,000

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$20 copayment per visit

Maternity Care (prenatal and postnatal)

$50 copayment first visit, then deductible, then 50%

Specialist Visit

$50 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

$300, then deductible, then 50%

Outpatient Hospital Services

Deductible, then 50%

Emergency Room

$300, then deductible, then 50%

Ambulance

Deductible, then 50%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 50%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 50%; 15 combined visits per benefit year.

Transplants

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

Silver 3001

Plan BenefitsIn Network Only
Deductible (single/family)

$3,000/$6,000

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$30 copayment per visit

Maternity Care (prenatal and postnatal)

$80 copayment first visit, then deductible, then 35%

Specialist Visit

$80 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible, then 35%

Outpatient Hospital Services

Deductible, then 35%

Emergency Room

$300 copayment, then deductible, then 35%

Ambulance

Deductible, then 35%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Durable Medical Equipment

Deductible, then 35%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 35%; 15 combined visits per benefit year.

Transplants

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

Silver 3500

Plan BenefitsIn Network Only
Deductible (single/family)

$3,500/$7,000

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$0 copayment per visit

Maternity Care (prenatal and postnatal)

$60 copayment first visit, then deductible, then 30%

Specialist Visit

$60 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible, then 30%

Outpatient Hospital Services

Deductible, then 30%

Emergency Room

Deductible, then 30%

Ambulance

Deductible, then 30%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 30%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 30%; 15 combined visits per benefit year.

Transplants

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

Silver 3501

Plan BenefitsIn Network Only
Deductible (single/family)

$3,500/$7,000

Maximum Out Of Pocket (single/family)

$7,500/$15,000

Primary Care Physician Services

$0 copayment per visit

Maternity Care (prenatal and postnatal)

$60 first visit; deductible, then 40%

Specialist Visit

$60 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible, then 40%

Outpatient Hospital Services

Deductible, then 40%

Emergency Room

Deductible, then 40%

Ambulance

Deductible, then 40%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 40%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 40%; 15 combined visits per benefit year.

Transplants

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

Silver 4000

Plan BenefitsIn Network Only
Deductible (single/family)

$4,000/$8,000

Maximum Out Of Pocket (single/family)

$6,600/$13,200

Primary Care Physician Services

$15 copayment per visit

Maternity Care (prenatal and postnatal)

$40 copayment first visit, then deductible, then 30%

Specialist Visit

$40 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

$300, then deductible, then 30%

Outpatient Hospital Services

Deductible, then 30%

Emergency Room

$300 copayment, then deductible, then 30%

Ambulance

Deductible, then 30%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 30%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 30%; 15 combined visits per benefit year.

Transplants

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

Silver 4200

Plan BenefitsIn Network Only
Deductible (single/family)

$4,200/$8,400

Maximum Out Of Pocket (single/family)

$4,200/$8,400

Primary Care Physician Services

Deductible

Maternity Care (prenatal and postnatal)

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 as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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; 15 combined visits per benefit year.

Transplants

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

Silver 4500 HD

Plan BenefitsIn Network Only
Deductible (single/family)

$4,500/$9,000

Maximum Out Of Pocket (single/family)

$4,500/$9,000

Primary Care Physician Services

Deductible

Maternity Care (prenatal and postnatal)

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 as any other medical benefit

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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, 15 combined visits per benefit year.

Transplants

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

Silver 5001

Plan BenefitsIn Network Only
Deductible (single/family)

$5,000/$10,000

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$35 copayment per visit

Maternity Care (prenatal and postnatal)

$75 copayment first visit, then deductible, then 30%

Specialist Visit

$75 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible, then 30%

Outpatient Hospital Services

Deductible, then 30%

Emergency Room

$300 copayment, then deductible, then 30%

Ambulance

Deductible, then 30%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 30%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 30%; 15 combined visits per benefit year.

Transplants

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

Silver 5004HD

Plan BenefitsIn Network Only
Deductible (single/family)

$5,000/$10,000

Maximum Out Of Pocket (single/family)

$5,000/$10,000

Primary Care Physician Services

Deductible

Maternity Care (prenatal and postnatal)

Deductible

Specialist Visit

Deductible

Urgent Care

Deductible

Inpatient Hospital Services

Deductible

Outpatient Hospital Services

Deductible

Freestanding Ambulatory Surgical Center

Deductible

Emergency Room

Deductible

Ambulance

Deductible

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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; 15 combined visits per benefit year.

Transplants

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

Silver 6002

Plan BenefitsIn Network Only
Deductible (single/family)

$6,000/$12,000

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$0 copayment per visit

Maternity Care (prenatal and postnatal)

$35 copayment first visit, then deductible, then 20%

Specialist Visit

$35 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

$300, then deductible, then 20%

Outpatient Hospital Services

Deductible, then 20%

Emergency Room

$300, then deductible, then 20%

Ambulance

Deductible, then 20%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Durable Medical Equipment

Deductible, then 20%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 20%; 15 combined visits per benefit year

Transplants

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

Silver 6250

Plan BenefitsIn Network Only
Deductible (single/family)

$6,250/$12,500

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$0 copayment per visit

Maternity Care (prenatal and postnatal)

$35 copayment first visit, then deductible, then 25%

Specialist Visit

$35 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible, then 25%

Outpatient Hospital Services

Deductible, then 25%

Emergency Room

Deductible, then 25%

Ambulance

Deductible, then 25%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Durable Medical Equipment

Deductible, then 25%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 25%; 15 combined visits per benefit year

Transplants

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

Silver 6251

Plan BenefitsIn Network Only
Deductible (single/family)

$6,250/$12,500

Maximum Out Of Pocket (single/family)

$7,750/$15,500

Primary Care Physician Services

$0 copayment per visit

Maternity Care (prenatal and postnatal)

$35 copayment first visit, then deductible, then 25%

Specialist Visit

$35 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible, then 25%

Outpatient Hospital Services

Deductible, then 25%

Emergency Room

Deductible, then 25%

Ambulance

Deductible, then 25%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Durable Medical Equipment

Deductible, then 25%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 25%; 15 combined visits per benefit year

Transplants

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

Silver 6900

Plan BenefitsIn Network Only
Deductible (single/family)

$6,900/$13,800

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$0

Maternity Care (prenatal and postnatal)

$35 first visit, then deductible, then 40%

Specialist Visit

$35 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible, then 40%

Outpatient Hospital Services

Deductible, then 40%

Freestanding Ambulatory Surgical Center

$200 per visit

Emergency Room

Deductible, then 40%

Ambulance

Deductible, then 40%

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 40%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 40%; 15 combined visits per benefit year.

Transplants

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

Silver 7350

Plan BenefitsIn Network Only
Deductible (single/family)

$7,350/$14,700

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$25 copayment per visit

Maternity Care (prenatal and postnatal)

$60 copayment first visit, then deductible

Specialist Visit

$60 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 as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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; 15 combined visits per benefit year.

Transplants

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

Silver 7750

Plan BenefitsIn Network Only
Deductible (single/family)

$7,750/$15,500

Maximum Out Of Pocket (single/family)

$7,750/$15,500

Primary Care Physician Services

$25 copayment per visit

Maternity Care (prenatal and postnatal)

$60 copayment first visit, then deductible

Specialist Visit

$60 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible

Outpatient Hospital Services

Deductible

Emergency Room

Deductible

Ambulance

Deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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; 15 combined visits per benefit year.

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 BenefitsIn Network Only
Deductible (single/family)

$5,500/$11,000

Maximum Out Of Pocket (single/family)

$6,600/$13,200

Primary Care Physician Services

Deductible, then 50%

Maternity Care (prenatal and postnatal)

Deductible, then 50%

Specialist Visit

Deductible, then 50%

Urgent Care

Deductible, then 50%

Inpatient Hospital Services

Deductible, then 50%

Outpatient Hospital Services

Deductible, then 50%

Emergency Room

Deductible, then 50%

Ambulance

Deductible, then 50%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 50%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 50%; 15 combined visits 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 5501

Plan BenefitsIn Network Only
Deductible (single/family)

$5,500/$11,000

Maximum Out Of Pocket (single/family)

$7,900/$15,800

Primary Care Physician Services

Deductible, then 50%

Maternity Care (prenatal and postnatal)

Deductible, then 50%

Specialist Visit

Deductible, then 50%

Urgent Care

Deductible, then 50%

Freestanding Ambulatory Surgical Center

Deductible, then 50%

Inpatient Hospital Services

Deductible, then 50%

Outpatient Hospital Services

Deductible, then 50%

Emergency Room

Deductible, then 50%

Ambulance

Deductible, then 50%

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 50%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 50%; 15 combined visits per benefit year.

Transplants

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

Bronze 6000HD

Plan BenefitsIn Network Only
Deductible (single/family)

$6,000/$12,000

Maximum Out Of Pocket (single/family)

$6,000/$12,000

Primary Care Physician Services

Deductible

Maternity Care (prenatal and postnatal)

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 as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Mammogram

$0

Prescription Drugs

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

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; 15 combined visits 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 6350HD

Plan BenefitsIn Network Only
Deductible (single/family)

$6,350/$12,700

Maximum Out Of Pocket (single/family)

$6,350/$12,700

Primary Care Physician Services

Deductible

Maternity Care (prenatal and postnatal)

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 as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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; 15 combined visits 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
Deductible (single/family)

$6,500/$13,000

Maximum Out Of Pocket (single/family)

$6,850/$13,700

Primary Care Physician Services

Deductible, then 50%

Maternity Care (prenatal and postnatal)

Deductible, then 50%

Specialist Visit

Deductible, then 50%

Urgent Care

Deductible, then 50%

Inpatient Hospital Services

Deductible, then 50%

Outpatient Hospital Services

Deductible, then 50%

Emergency Room

$300, then deductible, then 50%

Ambulance

Deductible, then 50%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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

Deductible, then 50%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 50%; 15 combined visits per benefit year.

Transplants

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

Bronze 7150

Plan BenefitsIn Network Only
Deductible (single/family)

$7,150/$14,300

Maximum Out Of Pocket (single/family)

$7,150/$14,300

Primary Care Physician Services

$45 copayment

Maternity Care (prenatal and postnatal)

$90 first visit, deductible.

Specialist Visit

$90 copayment per visit

Urgent Care

$50 copayment per visit

Freestanding Ambulatory Surgical Center

$200 per visit

Inpatient Hospital Services

Deductible

Outpatient Hospital Services

Deductible

Emergency Room

Deductible

Ambulance

Deductible

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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; 15 combined visits per benefit year.

Transplants

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

Bronze 7350

Plan BenefitsIn Network Only
Deductible (single/family)

$7,350/$14,700

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$45 copayment per visit

Maternity Care (prenatal and postnatal)

$90 first visit, deductible

Specialist Visit

$90 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible

Outpatient Hospital Services

Deductible

Emergency Room

Deductible

Ambulance

Deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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; 15 combined visits per benefit year.

Transplants

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

Bronze 7900

Plan BenefitsIn Network Only
Deductible (single/family)

$7,900/$15,800

Maximum Out Of Pocket (single/family)

$7,900/$15,800

Primary Care Physician Services

Deductible

Maternity Care (prenatal and postnatal)

Deductible

Specialist Visit

Deductible

Urgent Care

Deductible

Freestanding Ambulatory Surgical Center

Deductible

Inpatient Hospital Services

Deductible

Outpatient Hospital Services

Deductible

Emergency Room

Deductible

Ambulance

Deductible

Mental Health and Substance Abuse

Covered as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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; 15 combined visits per benefit year.

Transplants

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

Bronze 7901

Plan BenefitsIn Network Only
Deductible (single/family)

$7,900/$15,800

Maximum Out Of Pocket (single/family)

$7,900/$15,800

Primary Care Physician Services

$50 copayment per visit

Maternity Care (prenatal and postnatal)

$100 first visit, deductible

Specialist Visit

$100 copayment per visit

Urgent Care

$50 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 as any other medical benefit.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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; 15 combined visits per benefit year.

Transplants

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

Catastrophic Plan

Catastrophic

Plan BenefitsIn Network Only
Deductible (single/family)

$7,900/$15,800

Maximum Out Of Pocket (single/family)

$7,900/$15,800

Primary Care Physician Services

$25 for first three visits; deductible thereafter

Maternity Care (prenatal and postnatal)

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 as any other medical benefit

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

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; 15 combined visits per benefit year

Transplants

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

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