Blue Cross Select Silver
Calendar Year Deductible: $2,800 individual or $5,600 maximum for the entire family.
Out-of-Pocket Maximum: $7,350 individual or $14,700 for the entire family.
IMPORTANT: This plan uses the Select Lab Network.
BENEFIT REQUIREMENTS
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.
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 | ||
|---|---|---|---|
 |
PHYSICIAN VISITS Primary Care Select Physician and Specialist |
Primary Care Select Physician: $40 copay
Specialist: $65 copay when Primary Care Select Physician refers you |
100% after copay |
 |
OUTPATIENT SURGERY | Lower Member Cost Share: $575 copay
Higher Member Cost Share: $1,000 copay |
100% after copay |
 |
EMERGENCY ROOM For a medical emergency |
$600 copay | 100% after copay |
 |
INPATIENT HOSPITAL CARE Co-Pays vs Co-Insurance |
Lower Member Cost Share: 20% coinsurance
Higher Member Cost Share: 25% coinsurance |
Lower Member Cost Share: 80% coinsurance
Higher Member Cost Share: 75% coinsurance |
 |
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: $65 copay |
100% after copay |
 |
PRESCRIPTION DRUGS Source+Rx 1.0 Drug List |
Tier 1: $20
Tier 2: $30 Tier 3: $85 Tier 4:$150 copay or 50% coinsurance (whichever is greater) Tier 5: $250 TIer 6: $300 copay or 30% coinsurance (whichever is greater)
|
Tier 1-6: 100% after 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: $575 copay
Higher Member Cost Share: $1,000 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.
Last Updated: 11/01/2017 00:14
