Silver 6250

Plan type:

Details: 
Plan BenefitsIn Network Only
Coinsurance

25%

Deductible (single/family)

$6,250/$12,500

Maximum Out Of Pocket (single/family)

$7,800/$15,600

Primary Care Physician Services

$20 copayment per visit

Doctors Care/Blue CareOnDemand

$20 copayment per visit

Maternity Care

$55 copayment first visit

Specialist Visit

$55 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

25% after deductible

Outpatient Hospital Services

25% after deductible

Emergency Room

25% after deductible

Ambulance

25% after deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

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

Specialty Pharmaceuticals

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

Durable Medical Equipment

25% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

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

Transplants

A BlueChoice-participating facility must provide services.

Weight: 
-5