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BCBS of AZ BlueChoice HMO Medical Plan
February 1, 2004 - January 31, 2005
MEDICAL-BlueChoice MEDICAL-BluePreferred Dental
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Information provided is in summary format. Any difference between the summary provided and actual contract will be settled in favor of the contract. |
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| Medical Coverage Description |
Benefit |
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Inpatient Hospital, Outpatient Hospital, Skilled nursing Facility, X-Rays Covered Percentage |
90% |
| Professional Covered Percentage | 100% |
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Out-of-Pocket Max |
$500 (per person) |
| Office Visit Copayment-Primary Care |
$15 |
| Office Visit Copayment-Specialist | $35 |
| Urgent Care Copayment | $75 |
| Emergency Room Copayment (per visit) | $75 |
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Ambulance Covered Percentage |
100% |
| Inpatient Rehab Therapy, Home Health Care, Hospice, Prosthetic Appliances & DME | 100% |
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Emergency Room |
90% after deductible |
| Prescription Coverage Description | |
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Generic Drug Copayment (Level 1) |
$5 |
| Preferred Brand Drug Copayment (Level 2) | $20 |
| Non-Preferred Brand "A" Drug (Level 3) | $40 |
| Non-Preferred Brand "B" Drug (Level 4) | $80 |
| Mail Order Drugs |
1 Copayment per 90-Day Supply |
| Vision Coverage Description | |
| Avesis Routine Eye Exam Copayment* |
$15 |
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Chiropractic Office Visit (12 visits per calendar year) |
$15 |
| Behavioral and Mental Health Services | |
| Biodyne Copayment (Per Visit) |
$10 |
| Biodyne Copayment Maximum Per Calendar Year (Per Person) |
$100 |
| Biodyne Copayment Maximum Per Calendar Year (Per Family) |
$200 |
| Non-Biodyne Behavioral & Mental Health Services - For further benefit information see your benefit booklet. | |
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* Available in Arizona Only
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