Blue Cross Blue Shield of Arizona BluePreferred Plan Comparison Benefits BluePreferred Plan 100 BluePreferred Copay 100 BluePreferred Copay 250 BluePreferred Copay 500 Blue Preferred Copay 1000 Blue Preferred Copay 2000 Deductibles* Non- Coinsurance Non- Out-of-Pocket Max 1 Non- Office Visit Non- Non- Routine Mammogram Non- Non- Inpatient Hospital Non- Outpatient Surgery Non- Emergency Prescription Drugs 2 Non- Lab Non- In-Network Vision Exam Eyewear X-ray Non- $100 single, $200 family up to $1,000 1 up to $2,000 1, deductible waived, deductible waived, deductible waived then, 1 visit per year $100 single, $200 family up to $1,000 1 up to $2,000 1, deductible waived, deductible waived then, 1 visit per year $250 single, $500 family up to $2,000 1 up to $4,000 1, deductible waived, deductible waived then, 1 visit per year $500 single, $1000 family up to $2,500 1 up to $5,000 1, deductible waived, deductible waived then, 1 visit per year $1000 single, $2,000 family up to $3,000 1 up to $6,000 1, deductible waived, deductible waived $50 copay $100 additional copay, then $10/$30/$60/$120, 1 visit per year $2,000 single, $4,000 family up to $4,000 1 up to $8,000 1 $30 copay $30 copay, deductible waived, deductible waived $50 copay $100 additional copay, then $10/$30/$60/$120 $30 copay, 1 visit per year 1 Per person per calendar year out-of-pocket. 2 Generic/Preferred Brand/Non-Preferred Brand A /Non-Preferred Brand B. When a pharmacy s prescription drug price is less than the copayment, the pharmacy may charge you its usual and customary price. This may not be the price charged to BCBSAZ, because in most cases the BCBSAZ price is lower than the pharmacy s usual and customary price, which varies by pharmacy. Out-of-Network: Reimbursement of BCBSAZ allowed amount less applicable copay, deductible or coinsurance. Member pays difference between allowed amount and billed charges. *Deductible applies unless otherwise indicated. Preventive Care: Well care (as defined in the Benefit Plan Booklet) for men, women, children is covered In-Network only, deductible waived; applicable copays or coinsurance apply. Contract Maximum for above plans is $2 million lifetime benefit per individual. Medical necessity: For services to be covered by this benefit plan, they must be considered medically necessary by BCBSAZ, based on specific criteria which is available to you upon request. Where benefits are provided by a third party administrator such as Biodyne, the third party administrator may determine medical necessity based on its own criteria. This illustration is for comparative purposes only. Please refer to the Benefit Plan Booklet for a complete listing and description of all benefits, limitations and exclusions which will be sent out upon enrollment, or upon request prior to enrollment.
Blue Cross Blue Shield of Arizona BlueSelect Plan Comparison Benefit Category BlueSelect HMO Plan 10 BlueSelect HMO Plan 15 BlueSelect HMO Plan 20 Office Visits $10 copay $20 copay Preventive Care of covered services of covered services of covered services after office visit copay after office visit copay after office visit copay Hospital Services Inpatient of covered services $250 copay per admission $500 copay per admission $500 family maximum $1000 family maximum Outpatient of covered services of covered services of covered services Prescription Drugs* Generic $7 copay $7 copay $7 copay Preferred Brand $20 copay $20 copay $20 copay Non-Preferred Brand A $40 copay $40 copay $40 copay Non-Preferred Brand B $80 copay $80 copay $80 copay Lab & X-ray of covered services of covered services of covered services Hospital Emergency Room $50 copay $75 copay $75 copay Vision Exam $10 copay, 1 visit per year, 1 visit per year $20 copay, 1 visit per year Eyewear Behavioral Health-Biodyne Exclusive Inpatient of covered services $250 copay $500 copay 30 days per 24 months 30 days per 24 months 30 days per 24 months Outpatient $10 copay per visit to a maximum $10 copay per visit to a maximum $10 copay per visit to a maximum of $100 per person, of $100 per person, of $100 per person, $200 maximum per family $200 maximum per family $200 maximum per family All plans include Chiropractic benefits for 12 medically necessary visits for neck and back pain, per calendar year, provided through the chiropractic service administrator. Office visit copay applies. No PCP referral necessary. 2 Generic/Preferred Brand A /Non-Preferred Brand B. When a pharmacy s prescription drug price is less than the copayment, the pharmacy may charge you its usual and customary price. This may not be the price charged to BCBSAZ, because in most cases the BCBSAZ price is lower than the pharmacy s usual and customary price, which varies by pharmacy. Out-of-Network: Reimbursement of BCBSAZ allowed amount less applicable copay. Member pays difference between allowed amount and billed charges. Routine Physical and Preventive Care: Well care for men, women, children as defined in the Benefit Plan Booklet, is covered In-Network only, deductible waived, applicable copays apply. Medical necessity: For services to be covered by this benefit plan, they must be considered medically necessary by BCBSAZ, based on specific criteria, which is available to you upon request. Where benefits are provided by a third party administrator such as Biodyne, the third party administrator may determine medical necessity based on their own criteria. This illustration is for comparative purposes only. Please refer to the Benefit Plan Booklet for a complete listing and description of all benefits, limitations and exclusions, which will be sent out upon enrollment, or upon request prior to enrollment.
Blue Cross Blue Shield of Arizona BlueAdvantage Plan Comparison Blue Advantage Option 1 Blue Advantage Option 2 In-Network Out-of-Network In-Network Out-of-Network Calendar Year Deductible* Not applicable $250, family maximum of $500 Not applicable $500, family maximum of $1,000 Coinsurance unless otherwise stated unless otherwise stated unless otherwise stated unless otherwise stated Out-of-Pocket Maximum $1,000 1 $8,000 1 $2,000 1 $8,000 1 Office Visit - PCP Office Visit - Specialist Routine Physical, after copay after copay Immunizations, Well-woman Routine Mammogram, deductible waived, deductible waived, deductible waived, deductible waived Prescription Drug 2 2 Inpatient Hospital $250 copay, then $250 copay, then $500 copay, then $500 copay, then Outpatient Surgery Emergency $75 copay $75 copay $75 copay, then $75 copay, then Behavioral Health: Outpatient $10 copay $10 copay $100/200 annual max. $100/200 annual max. Inpatient $250 copay then $500 copay then up to a maximum of up to a maximum of 30 days/24 mo. period 30 days/24 mo. period Lab X-ray Vision Care One exam/year, plus One exam/year, plus 1 Per person per calendar year out-of-pocket. 2 Generic/Preferred Brand/Non-Preferred Brand A /Non-Preferred Brand B. When a pharmacy s prescription drug price is less than the copayment, the pharmacy may charge you its usual and customary price. This may not be the price charged to BCBSAZ, because in most cases the BCBSAZ price is lower than the pharmacy s usual and customary price, which varies by pharmacy. Out of Network: Reimbursement of BCBSAZ allowed amount less applicable copay. Member pays difference between allowed amount and billed charges. *Deductibles apply unless otherwise indicated. Preventive Care: Annual physicals, immunizations, well care, as defined in the benefit booklet, are covered In-Network only; deductible waived; applicable copays apply There is no Contract Maximum for above plans. Medical necessity: For services to be covered by this benefit plan, they must be considered medically necessary by BCBSAZ, based on specific criteria which is available to you upon request. Where benefits are provided by a third party administrator such as Biodyne, the third party administrator may determine medical necessity based on their own criteria. This illustration is for comparative purposes only. Please refer to the Benefit Plan Booklet for a complete listing and description of all benefits, limitations and exclusions which will be sent out upon enrollment or upon request prior to enrollment.
Blue Cross Blue Shield of Arizona Dual Option I HMO/ Plan Comparison Office Visits $10 copay Inpatient Outpatient Surgery Hospital Emergency Room $50 copay Prescription Drugs 2 Lab & X-ray Vision Exam Eyewear Chiropractic HMO Option - BlueSelect Plan 10 Option - Blue Preferred Copay 250 $10 copay, 1 visit per year 12 medically necessary visits per calendar year for neck and back pain, applicable copay applies Deductible* $250 single, $500 family Non- (cumulative in- and out-of-network) Coinsurance ; Non- Out-of-pocket Max up to $2,000 1 ; Non- up to $4,000 1 Office Visit copays Non- Routine Mammography, deductible waived Non-, deductible waived Non- Inpatient Hospital Non- Outpatient Surgery Non- Emergency $50 additional copay; then Vision exam, In-Network, 1 visit per year Eyewear, In-Network Prescription Drugs 2 Non- Allowable amount less copay Lab Non- X-ray Non-
Blue Cross Blue Shield of Arizona Dual Option II HMO/ Plan Comparison Office Visits Inpatient $20 copay $500 copay per admission $1,000 calendar year maximum copay per family Outpatient Surgery Hospital Emergency Room $75 copay Prescription Drugs 2 Lab & X-ray Vision Exam Eyewear Chiropractic HMO Option - BlueSelect Plan 20 Option - Blue Preferred Copay 500 $20 copay, 1 visit per year 12 medically necessary visits per calendar year for neck and back pain, applicable copay applies Deductible* $500 single, $1,000 family Non- (cumulative in- and out-of-network) Coinsurance ; Non- Out-of-pocket Max up to $3,000 1 ; Non- up to $6,000 1 Office Visit copays Non- Routine Mammography, deductible waived Non-, deductible waived Non- Inpatient Hospital Non- Outpatient Surgery Non- Emergency $50 additional copay; then Vision exam, In-Network, 1 visit per year Eyewear, In-Network Prescription Drugs 2 Non- Allowable amount less copay Lab Non- X-ray Non- 1 Per person per calendar year out-of-pocket. 2 Generic/Preferred Brand/Non-Preferred Brand A /Non-Preferred Brand B. When a pharmacy s prescription drug price is less than the copayment, the pharmacy may charge you its usual and customary price. This may not be the price charged to BCBSAZ, because in most cases the BCBSAZ price is lower than the pharmacy s usual and customary price, which varies by pharmacy. Out-of-Network: Reimbursement of BCBSAZ allowed amount less applicable copay. Member pays difference between allowed amount and billed charges. *Deductibles apply unless otherwise indicated. Preventive Care includes: physical exams, well-child care, immunizations, gynecologic exams, Pap tests, mammograms, sigmoidoscopies, and PSA blood tests, as set forth in the Benefit Plan Booklet Contract Maximum for above plan is $2 million lifetime benefit per individual. Lifetime Benefit Maximum Per Individual for HMO plan is unlimited. Medical necessity: For services to be covered by this benefit plan, they must be considered medically necessary by BCBSAZ, based on specific criteria which is available to you upon request. Where benefits are provided by a third party administrator such as Biodyne, the third party administrator may determine medical necessity based on their own criteria. This illustration is for comparative purposes only. Please refer to the Benefit Plan Booklet, for a complete listing and description of all benefits, limitations and exclusions which will be sent upon enrollment or prior to enrollment upon request.
Exclusions and Limitations Abortions (non-spontaneous, medically induced, except when fetus/newborn not expected to be viable) Activity therapy Acupuncture Alternative medicine non-traditional or alternative medical therapies, including but not limited to: naturopathic and homeopathic medicine, diet therapies, nutritional or lifestyle therapies, aromatherapy Biofeedback and/or hypnotherapy, (except as provided by Biodyne) Chiropractic services, except as specified in the benefit plan Cognitive and vocational therapy Complications of body piercing/tattooing Complications of non-covered benefits Cosmetic or aesthetic surgery except for breast reconstruction following a medically necessary mastectomy in accordance with state and/or federal law, or for congenital defects for newborns and adopted children Counseling (except as may be available through Biodyne) Court-ordered services testing, treatment or therapy, unless such services are otherwise covered under the benefit plan Custodial care except for limited hospice benefits Dental/orthodontic services or supplies Dietary/nutritional supplements all dietary, caloric and nutritional supplements, including, for example, specialized formulas for infants, children or adults, or other special foods or diets, even if prescribed by a physician or other eligible provider, except as otherwise specifically provided under the Medical Foods section of the Benefit Plan Booklet. Environmental medicine Fees other than for medically appropriate in-person, direct patient treatment, tests, services, medications, supplies or equipment Fertility or infertility treatment, drugs, or procedures Foot care, except when medically appropriate for diabetics, neurological involvement, or peripheral vascular disease of the foot or lower leg Government services services available under a governmental health program Hearing services hearing aid services and supplies and routine hearing exams except for hearing screening that may be included in covered physical exams Investigational treatments, procedures, equipment, drugs, devices, or supplies, as determined by BCBSAZ, and only as required by Arizona law Lodging and meals Non-medically necessary services as determined by BCBSAZ. BCBSAZ may not be able to determine medical necessity until after services are rendered Over-the-counter drugs any drug, medicine, device, equipment, supply (except for certain diabetic supplies as described in the pharmacy benefit), that is lawfully obtainable without a prescription; vitamins, minerals, and drugs dispensed by or from the physician s office Personal comfort items Services or supplies prior to effective date Services or supplies after termination Services or Supplies Related to or Associated with a Non-covered Service or Supply Services from family member(s) - services that are provided by an eligible provider who is a member of your immediate family, or services for which you have no legal obligation to pay Services of ineligible providers Services not requiring a licensed professional Services without a prescription Sexual dysfunction evaluation and/or testing, diagnosis, treatment (surgical or non-surgical), or medication or devices for sexual dysfunction regardless of the cause of the condition Smoking-cessation programs (except as provided by Biodyne), medications, aids or devices Telephonic or electronic consultations Therapy services, except as expressly provided in the benefit plan Training and education, except for certain diabetic training specifically approved in advance by BCBSAZ, or training related to BCBSAZ established disease management program(s) with advance BCBSAZ approval Transplants (organ, tissue, bone marrow/peripheral stem cell rescue procedures) not approved as a covered benefit by BCBSAZ; nor high-dose chemotherapy, radiation administered in conjunction with a non-covered transplant Transportation - transport services or travel expenses except as described in the ambulance benefit Transsexual treatment or surgery and/or any related services Vision therapy, radial keratotomy, all types of refractive keratoplasties, eye glasses and contact lenses and the vision examination for prescribing and fitting of the same, except as otherwise stated as a benefit in the benefit plan Vitamins except for prenatal vitamins when a prescription is written by a physician Weight loss/gain therapy or treatment, including Xenical (except for certain surgical services, or as may be provided by Biodyne) Workers Compensation services for an illness or injury covered by Workers Compensation or similar benefits, unless you are exempt from such coverage or have made a statutory opt-out election