Blue Cross Blue Shield of Arizona

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

Plan Overview

Medical Deductible
  • Individual: $4,750.00
  • Family: $9,500
  • Per Person: $4,750
Prescription Drug Deductible
  • Individual: $600.00
  • Family: not applicable
  • Per Person: $600
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $8,700.00
  • Family: $17,400
  • Per Person: $8,700

Office Visit

Primary Doctor
  • CoPay: $20.00
  • 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: $75.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $75.00 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: 40.00% Coinsurance after deductible
  • Covered: Covered
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 40.00% Coinsurance after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: 40.00% 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: 40.00% 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: $75.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: $20.00
  • 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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