Silver 7350

Plan type:

Details: 
Plan BenefitsIn Network Only
Coinsurance

0%

Deductible (single/family)

$7,350/$14,700

Maximum Out Of Pocket (single/family)

$7,350/$14,700

Primary Care Physician Services

$40 copayment per visit

Doctors Care/Blue CareOnDemand

$40 copayment per visit

Maternity Care

$80 copayment first visit

Specialist Visit

$80 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 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: $35 retail/$70 mail order;
Tier 2: $35 retail/$70 mail order;
Tier 3: $60 retail/$120 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

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: 
-2