Blue Cross Blue Shield of Arizona

Blue EverydayHealth Gold (2 Free Primary Care In-Person/Virtual Visits)

Plan Overview

Medical Deductible
  • Individual: $2,000.00
  • Family: $4,000
  • Per Person: $2,000
Prescription Drug Deductible
  • Individual: $400.00
  • Family: not applicable
  • Per Person: $400
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $7,250.00
  • Family: $14,500
  • Per Person: $7,250

Office Visit

Primary Doctor
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Exclusions: First 2 visits per person per calendar year are covered at no charge. Copay for additional PCP visits. 24/7 online doctor visits available with BlueCare Anywhere - see SBC for more information.
  • Benefit Explanation: First 2 visits per person per calendar year are covered at no charge. Copay for additional PCP visits. 24/7 online doctor visits available with BlueCare Anywhere - see SBC for more information.
Specialist
  • CoPay: $50.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $70.00 Copay after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.
Generic Drugs
  • CoPay: $3.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Exclusions: Prescription drugs in Tier 1a: New low copays on 30-day supplies of common everyday prescriptions including select insulin. Copays as low as $0 or $3, depending upon your plan. Find out if your prescriptions are on the BCBSAZ Tier1a Drug List at https://azblue.com/pharmacy-management/Tier1a-Drug-List. Prescription drugs in Tier 1b have low copays that range from $5 to $20 on a 30-day supply, depending upon your plan. Excludes medications not on the formulary, unless a formulary exception is approved.
  • Benefit Explanation: Prescription drugs in Tier 1a: New low copays on 30-day supplies of common everyday prescriptions including select insulin. Copays as low as $0 or $3, depending upon your plan. Find out if your prescriptions are on the BCBSAZ Tier1a Drug List at https://azblue.com/pharmacy-management/Tier1a-Drug-List. Prescription drugs in Tier 1b have low copays that range from $5 to $20 on a 30-day supply, depending upon your plan.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00%
  • Covered: Covered
  • Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered
Urgent Care Facility
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the contract holder or covered spouse is confirmed through a court order or legal guardianship.
Pre and Postnatal Office Visit
  • CoPay: $50.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per Year
  • Benefit Explanation: Limit of 1 routine vision exam per calendar year.

Major Dental Care

Routine Dental Checkups for Children
  • CoPay: No Charge
  • CoInsurance: No Charge
  • Covered: Covered
  • Limit Quantity: 2
  • Limit Unit : Visit(s) per Year
  • Benefit Explanation: Limit of 2 dental check-ups & cleanings per year.
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We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN53901AZ1420007ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN53901AZ1420007ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN53901AZ1420007ACA1