Arkansas Blue Cross Blue Shield

Silver Value

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Combined Medical and Drug Deductible	Individual: $0.00 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,100.00 Family: $18200 Per Person: $9100

Primary Doctor	CoPay: $70.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Coverage includes 3 free visits for Primary Care Physician consultation and evaluation in-network services before copay applies.
Specialist	CoPay: $95.00 CoInsurance: Not Applicable Covered: Covered

Preferred Brand Drugs	CoPay: $280.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 75293AR1200023-01- $560 Copay in-network, 75293AR1200023-03- $560 Copay in-network, 75293AR1200023-04- $560 Copay in-network, 75293AR1200023-05- $560 Copay in-network, and 75293AR1200023-06- $560 Copay in-network.
Non Preferred Brand Drugs	CoPay: $1,600.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 75293AR1200023-01- $3200 Copay in-network, 75293AR1200023-03- $3200 Copay in-network, 75293AR1200023-04- $3200 Copay in-network, 75293AR1200023-05- $3200 Copay in-network, and 75293AR1200023-06- $900 Copay in-network.
Generic Drugs	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 75293AR1200023-01- $70 Copay in-network, 75293AR1200023-03- $70 Copay in-network, 75293AR1200023-04- $70 Copay in-network, 75293AR1200023-05- $60 Copay in-network, and 75293AR1200023-06- $30 Copay in-network.
Specialty Drugs	CoPay: $5,000.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Requires Prior Approval from the Company.

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

Emergency Room	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered
Urgent Care Facility	CoPay: $70.00 CoInsurance: Not Applicable Covered: Covered

Labor and Delivery Hospital Stay

CoPay: Not Applicable
CoInsurance: 50.00%
Covered: Covered
Benefit Explanation: Childbirth/delivery professional services: 75293AR1200023-01-50% Coinsurance for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200023-02-No charge for in-network and out-of-network services; 75293AR1200023-03-50% Coinsurance for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200023-04-50% Coinsurance for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200023-05-20% Coinsurance for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200023-06-10% Coinsurance for in-network services and 50% Coinsurance after deductible for 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: $30.00
CoInsurance: Not Applicable
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