Silver 7000

Plan type:

Details: 
Plan BenefitsIn Network Only
Coinsurance

0%

Deductible (single/family)

$7,000/$14,000

Maximum Out Of Pocket (single/family)

$7,000/$14,000

Primary Care Physician Services

$0 copayment per visit

Doctors Care/Blue CareOnDemand

$0 copayment per visit

Maternity Care

$50 first visit

Specialist Visit

$50 copayment per visit

Urgent Care

$50 copayment per visit

Inpatient Hospital Services

$500 copayment, then deductible

Outpatient Hospital Services

Deductible

Emergency Room

$500 copayment, then deductible

Ambulance

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: $25 retail/$50 mail order;
Tier 2: $25 retail/$50 mail order;
Tier 3: $45 retail/ $90 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 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: 
-1