Blue Cross Select Silver

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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.

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: $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.