Blue is now Silver.

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Check out our 2018 health plans and choose the one that best fits you. When you're ready to purchase your plan, you can:

It's Open Enrollment Time! Check out our 2018 Silver plans here. We offer a variety of Blue Option Silver plans for individuals and their families. You'll find summaries of each plan by clicking on the plan names.

While there are several different health plans for you to choose from, each Blue Option Silver plan includes the same basic vision and preventive dental benefits.

 

 

Plan List

Silver 1250

Plan BenefitsIn Network Only
Deductible (single/family)

1,250/2,500

Maximum Out Of Pocket (single/family)

6,500/13,000

Primary Care Physician Services

$40 copayment per visit

Maternity Care (prenatal and postnatal)

$80 copayment first visit

Specialist Visit

$80

Urgent Care

$50 copayment

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 (one 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%; 30 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 1500

Plan BenefitsIn Network Only
Deductible (single/family)

$1,500/$3,000

Maximum Out Of Pocket (single/family)

$6,600/$13,200

Primary Care Physician Services

$15 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

$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 (one 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%; 30 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)

$6,400/$12,800

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 (one 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%; 30 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 2502New

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

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 (one 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%; 30 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 2502New

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

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 (one 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%; 30 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)

$7,000/$14,000

Primary Care Physician Services

$20 copayment per visit

Maternity Care (prenatal and postnatal)

$50 copayment first visit

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 (one 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 deductible retail/$600, then deductible mail order;
Tier 6: $300, then deductible retail/$600, then deductible mail order

Durable Medical Equipment

Deductible, then 50%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 50%; 30 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)

$6,700/$13,400

Primary Care Physician Services

$30 copayment per visit

Maternity Care (prenatal and postnatal)

$80 copayment first visit

Specialist Visit

$80 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 (one 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: 30% retail/30% mail order;
Tier 6: 30% retail/30% mail order

Durable Medical Equipment

Deductible, then 30%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 30%; 30 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)

$5,900/$11,800

Primary Care Physician Services

$0 copayment per visit

Maternity Care (prenatal and postnatal)

$60 copayment first visit

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 (one 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%; 30 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 3850 HD

Plan BenefitsIn Network Only
Deductible (single/family)

$3,850/$7,700

Maximum Out Of Pocket (single/family)

$3,850/$7,700

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 (one 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; 30 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)

$6,000/$12,000

Primary Care Physician Services

$15 copayment per visit

Maternity Care (prenatal and postnatal)

$40 copayment first visit

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 (one 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%; 30 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 4002

Plan BenefitsIn Network Only
Deductible (single/family)

$4,000/$8,000

Maximum Out Of Pocket (single/family)

$7,000/$14,000

Primary Care Physician Services

$25 copayment per visit

Maternity Care (prenatal and postnatal)

Deductible, then 45%

Specialist Visit

Deductible, then 45%

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

Deductible, then 45%

Outpatient Hospital Services

Deductible, then 45%

Emergency Room

Deductible, then 45%

Ambulance

Deductible, then 45%

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered as any other medical benefit

Gynecologist Exam (one per benefit year)

$0

Routine Screening Mammogram

$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: Prescription deductible, then 45% retail. Prescription deductible is $200 per member per benefit period, $400 per family per benefit period./Prescription deductible, then 45% mail order.Prescription deductible is $200 per member per benefit period, $400 per family per benefit period.
Tier 4: Prescription deductible, then 45% retail. Prescription deductible is $200 per member per benefit period, $400 per family per benefit period./Prescription deductible, then 45% mail order. Prescription deductible is $200 per member per benefit period, $400 per family per benefit period.

Specialty Pharmaceuticals

Tier 5: Prescription deductible, then 45% retail. Prescription deductible is $200 per member per benefit period, $400 per family per benefit period./Prescription deductible, then 45% mail order. Prescription deductible is $200 per member per benefit period, $400 per family per benefit period.;
Tier 6: Prescription deductible, then 45% retail. Prescription deductible is $200 per member per benefit period, $400 per family per benefit period./Prescription deductible, then 45% mail order. Prescription deductible is $200 per member per benefit period, $400 per family per benefit period.

Durable Medical Equipment

Deductible, then 45%

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible, then 45%; 30 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 (one 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, 30 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

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 (one 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%; 30 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 (one 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; 30 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

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 (one 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%; 30 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

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 (one 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%; 30 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

Specialist Visit

$35

Inpatient Hospital Services

Deductible, then 40%

Outpatient Hospital Services

Deductible, then 40%

Urgent Care

$50 copayment per visit

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 (one 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: 40% after Deductible retail/40% after Deductible mail order;
Tier 6: 40% after Deductible retail/40% after Deductible mail order

Durable Medical Equipment

Deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

Deductible; 30 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

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 (one 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; 30 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.