Compare Plans
Silver Plan
Silver 1500
Plan Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: $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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In Network Only |
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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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In Network Only |
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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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In Network Only |
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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; |
Specialty Pharmaceuticals | Tier 5: $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 Benefits | In Network Only |
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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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In Network Only |
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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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In Network Only |
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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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In Network Only |
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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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In Network Only |
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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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In Network Only |
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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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: $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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: $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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: $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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: $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 Benefits | In 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; |
Specialty Pharmaceuticals | Tier 5: 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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