Silver 6850

Plan type:

Details: 
Plan BenefitsIn Network Only
Coinsurance

40%

Deductible (single/family)

$6,850/$13,700

Maximum Out Of Pocket (single/family)

$7,800/$15,600

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

Ambulance

40% after deductible

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: $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.

Transplants

A BlueChoice-participating facility must provide services.

Weight: 
-3