Silver 6850

Plan type:

Plan BenefitsIn Network Only


Deductible (single/family)


Maximum Out Of Pocket (single/family)


Primary Care Physician Services

$25 copayment per visit

Doctors Care/Blue CareOnDemand

$25 copayment per visit

Maternity Care

$60 first visit

Specialist Visit

$60 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

40% after deductible

Outpatient Hospital Services

40% after deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Emergency Room

40% after deductible


40% after deductible

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)


Routine Screening Mammogram


Routine Screening Colonoscopy


Prescription Drugs

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

Specialty Pharmaceuticals

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

Durable Medical Equipment

40% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

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


A BlueChoice-participating facility must provide services.