Arkansas Blue Cross Blue Shield

Bronze Exp Standardized

Links

Combined Medical and Drug Deductible	Individual: $7,500.00 Family: $15000 Per Person: $7500
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200.00 Family: $18400 Per Person: $9200

Primary Doctor	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered

Preferred Brand Drugs	CoPay: $50.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 75293AR1200024-01- $100 Copay after deductible in-network, and 75293AR1200024-03- $100 Copay after deductible in-network
Non Preferred Brand Drugs	CoPay: $100.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 75293AR1200024-01- $200 Copay after deductible in-network, and 75293AR1200024-03- $200 Copay after deductible in-network
Generic Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 75293AR1200024-01- $50 Copay in-network, and 75293AR1200024-03- $50 Copay in-network
Specialty Drugs	CoPay: $500.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Requires Prior Approval from the Company.

Hospital Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Requires prior notification to the Company.
Inpatient Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Emergency Room	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered

Labor and Delivery Hospital Stay

CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Childbirth/delivery professional services: 75293AR1200027-01-50% Coinsurance after deductible for in-network and out-of-network services; 75293AR1200027-02-No charge for in-network and out-of-network services; 75293AR1200027-03-50% Coinsurance after deductible for in-network and out-of-network services; Coverage for Out of Network newborn services is limited to $2000 per person for all services first 90 days after birth. Coverage requires Prior Notification to the Company.

Pre and Postnatal Office Visit

CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Requires Prior Notification to the Company. Coverage for routine ultrasound is limited to 1.

Routine Eye Exams for Children

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered