| Office Visit-Primary
Care Physician (PCP) |
$15
copay per visit (PCP-General Practice, Family Practice,
Internal Medicine, Pediatrics). |
| Office Visit- Specialist |
$35
copay per visit; no referral from PCP is required by
PLAN. Some specialists may still require a referral. |
| Laboratory |
PLAN pays
100%
for covered services. |
| X-Ray Services |
PLAN pays
100%
for covered services. |
| Inpatient Hospital – Physician/Surgeon* |
PLAN pays
100%
for covered services. |
Inpatient Facility -
Hospital* |
$100
copay per day to a maximum of
$300
per admission, then PLAN pays
100%
for covered services. |
Infertility
–
Professional
(In-vitro fertilization, GIFT, ZIFT, artificial insemination
not covered)
|
Office visit copay per visit.
$500
copay per surgury*; outpatient surgury & inpatient
admission copays also apply. |
| Sterilization* |
Office visit, outpatient surgury and
inpatient admission copays apply. |
Outpatient Surgery*
(facility charges)
|
$75
copay per visit, then plan pays
100%
for covered services. |
Outpatient Surgery*
(physician charges)
|
PLAN pays
100%
for covered services. |
| Ambulance |
PLAN pays
100%
for covered services. |
| Emergency Room |
$125
copay per visit; then PLAN pays
100%
for covered services; emergency room copay is waived
if you are admitted to the hospital. |
| Urgent Care |
$40
copay per visit.
Out-of-state -
If a member is outside Arizona and needs urgent medical
care, he/she may call the BlueCard Access network at
1-800-810-BLUE. Member will be directed to the nearest
network source of medical care. Covered services are
subject to the applicable copay, depending on where
you receive services. Pre-authorization may be required
for some services. |
Routine Physicals/
Preventive Care
|
PLAN pays
100%
for covered services. |
| Mammography |
PLAN pays
100%
for covered services. |
|
Maternity
|
Physician:
Office visit copay applies only to first prenatal
visit; additional applicable office visit copays
apply for covered services unrelated to routine
prenatal care; then PLAN pays 100% for covered
services.
Hospital: $100
copay per day to a maximum of
$300
per admission, then PLAN pays
100%
for covered services. |
| Physical, Occupational, and Speech
Therapy* |
Physical/Occupational/Speech Therapy:
PLAN pays
100%
for
60
visits per calendar year for PT,OT or ST or any combination,
no pre-authorization required. Additional visits beyond
60 require pre-authorization. |
| Cardiac Rehabilitation |
PLAN pays
100%
for a maximum of
60
visits per calendar year, no pre-authorization required. |
| Pulmonary Rehabilitation |
PLAN pays
100%
for a maximum of
60
visits per calendar year, no pre-authorization required. |
| Chiropractic* |
Chiropractic: $35
copay per visit to a maximum of
30
visits per calendar
year, available through the Chiropractic Services Administrator
(ASHN). |
| Durable Medical Equipment |
PLAN pays 100% for
covered services. (All diabetic supplies are excluded,
except blood glucose meters, insulin pumps and tubing) |
| External Prosthetic Devices |
PLAN pays 100% for
covered services up to a maximum of $2,000 per
calendar year (Maximum does not apply to external breast
prostheses). |
|
Behavioral/Mental Health*
(including Alcohol & Substance Abuse)
|
Behavioral health services must be
provided and/or authorized
exclusively
by the Behavioral Services Administrator (BSA).
Inpatient*:
$100
copay per day to a maximum of
$300
per admission, then PLAN pays
100%
for covered services to a maximum of
30
days per calendar year.
Inpatient Detoxification*:
$100
copay per day to a maximum of
$300
per admission, then PLAN pays
100%
for covered services to a maximum of
12
days† per calendar year.
Outpatient*:
Psychotherapy and counseling,
$10
copay per visit;
30
visits per calendar year.
Chemical Dependency Intensive Outpatient Program*:
$50
copay per program;
3
programs per calendar year; does not count towards
30
outpatient visit limit.
BSA services are available only in Arizona.
|
| Skilled Nursing Facility* |
PLAN pays
100%
for covered services. |
Inpatient Extended Active
Rehabilitation* |
PLAN pays
100%
for covered services. |
| Home Health Care* |
PLAN pays
100%
for covered services. |
| Hospice |
PLAN pays
100%
for covered services. |
|
Routine Vision Services
|
$5 copay for one routine vision exam
every 12 months when services received from BCBSAZ HMO vision providers. PLAN pays the
following allowed amount every 12 months for eyeglasses
and contact lenses:
Single
lenses
$20
Bifocal lenses
$30
Trifocal lenses
$40
Frames
$30
Contact lenses
$75
Member pays the difference between the cost of the
eyeglasses or contact
lenses and the allowed amount.
|
| Acupuncture Services* |
Office visit copay applies per visit;
subject to certain PLAN criteria and limitations. |
Hearing Exams and Hearing Aids
(includes semi-implantable hearing devices)
|
Office visit copay applies for hearing
exams. PLAN pays
100%
for covered services up to a maximum of
$2,000
per calendar year for hearing aids. |
| Contract Maximum |
Unlimited. |