Blue Cross Select Gold

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Calendar Year Deductible: $850 individual or $1,700 maximum for the entire family

Out-of-Pocket Maximum: $6,000 individual or $12,000 for the entire family

IMPORTANT: This plan uses the Select Lab Network.

This plan requires you and all covered members on the plan to designate a Primary Care Select Physician for benefits to be paid. If a Primary Care Select physician is not designated, no benefits are payable under the plan.

*In Alabama, you must be referred to a specialist by your Primary Care Select physician. If no referral, no benefits are payable under the plan.
    YOU PAY WE PAY
Physicians visits logo PHYSICIAN VISITS
Primary Care Select Physician and Specialist
Primary Care Select Physician: $35 copay
Specialist: $50 copay when your Primary Care Select Physician refers you
100% after the copay
OUTPATIENT SURGERY Lower Member Cost Share: $295 copay
Higher Member Cost Share: $600 copay
100% after the copay
EMERGENCY ROOM
For a medical emergency
$300 copay 100% after the copay
INPATIENT HOSPITAL CARE Lower Member Cost Share: $295 copay/ days 1-5
Higher Member Cost Share: $600 copay/ days 1-5
100% after the copay
MATERNITY CARE
Physician Benefits
0% after you meet the calendar year deductible 100% after you meet the calendar year deductible
MENTAL HEALTH
Office Visit or Consultation
Specialist: $50 copay 100% after the copay
PRESCRIPTION DRUGS
Source+Rx 1.0 Drug List
Tier 1: $10
Tier 2: $20
Tier 3: $45
Tier 4: $90 copay or 40% coinsurance (whichever is greater)
Tier 5: $175
Tier 6: $250 copay or 20% coinsurance (whichever is greater)
100% after the copay/ coinsurance
OCCUPATIONAL, PHYSICAL AND SPEECH THERAPY
Up to 30 visits per year
20% after you meet the calendar year deductible 80% after you meet the calendar year deductible
DIAGNOSTIC LAB Lower Member Cost Share: $295 copay
Higher Member Cost Share: $600 copay
100% after copay
ROUTINE IMMUNIZATIONS
AND PREVENTIVE SERVICES
AlabamaBlue.com/PreventiveServices
$0 100%
PEDIATRIC DENTAL & VISION
Routine Dental Cleaning: $0
Yearly Eye Exam: 20% after you meet the calendar year deductible
Routine Dental Cleaning: 100%
Yearly Eye Exam: 80% after you meet the calendar year deductible

*Benefits listed apply to in-network services. In-Network services outside of Alabama may vary.