The information on this site only presents highlights of your benefits and is still being updated. Please refer to the specific provisions found in your open enrollment materials for complete information on your benefits, limitations and exclusions.
 
BCBSAZ PPO Summary of Benefits
Summary of Benefits Preferred Provider (PPO) In-Network Non-Preferred Provider (Non-PPO)
Out-of-Network
    Member is responsible for the difference between the provider’s billed charges and the BCBSAZ allowed amount for covered services received from non-contracted providers (even after meeting the out-of-pocket maximum).††
Deductible $0 calendar year deductible. $400 calendar year deductible per person;
$800 calendar year family deductible maximum for a two member family; and
$1,200 calendar year family deductible maximum for a three or more member family.
Out-of-pocket Maximum $0 (excluding copays). $2,400 per person, $4,800 for a two member family, $5,200 for a three or more member family, per calendar year (includes deductible and excludes copays).After meeting the out-of-pocket maximum, PLAN pays 100% of the allowed amount for covered services during that calendar year.
For non-contracted providers: Member is responsible for the difference between the provider’s billed charges and the BCBSAZ allowed amount (even after meeting the out-of-pocket maximum). ††
Office Visit-Primary Care Physician (PCP) $15 copay per visit. (PCP - General Practice, Family Practice, Internal Medicine, Pediatrics). PLAN pays 70% for covered services, after meeting deductible. ††
Office Visit- Specialist $35 copay per visit.
Laboratory Services PLAN pays 100% for covered services. PLAN pays 70% for covered services, after meeting deductible. ††
X-Ray Services PLAN pays 100% for covered services. PLAN pays 70% for covered services, after meeting deductible. ††
Inpatient Hospital – Physician/Surgeon* PLAN pays 100% for covered services. PLAN pays 70% for covered services, after meeting deductible. ††
Inpatient Facility -
Hospital*		 $100 copay per day to a maximum of
$300 per admission, then PLAN pays
100% for covered services.		 $200 copay per day to a maximum of $600 per admission, then PLAN pays 70% for covered services, after meeting deductible. ††
Infertility – Professional
(In-vitro fertilization, GIFT, ZIFT, and
artificial insemination not covered)		 Office visit copay per visit.
$500 copay per surgery*; outpatient surgery and inpatient per admission copays apply.		 PLAN pays 70% for covered services, after meeting deductible. ††
Sterilization* Office visit, outpatient surgery, and inpatient per admission copays apply. $200 copay per day to a maximum of $600 per admission for inpatient surgery, then
PLAN pays 70% for covered services, aftervmeeting deductible. For outpatient surgery and office visits, PLAN pays 70% for covered services, after meeting deductible. ††
Outpatient Surgery*
(facility charges)		 $75 copay per visit, then PLAN pays
100% for covered services.		 PLAN pays 70% for covered services, after meeting deductible. ††
Outpatient Surgery*
(physician charges)		 PLAN pays 100% for covered services. PLAN pays 70% for covered services, after meeting deductible. ††
Ambulance PLAN pays 100% for covered services. 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. $40 copay per visit.

Routine Physicals/
Preventive Care
• Well child care
• Well woman care
• Well man care

 PLAN pays 100% for covered services. Not covered.
Mammography PLAN pays 100% for covered services. Routine mammograms not covered; PLAN pays 70% after meeting deductible for diagnostic mammograms. ††
Maternity
          Physician


          
          Hospital		 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. PLAN pays 70% for covered services, after meeting deductible. ††
$100 copay per day to a maximum of $300 per admission, then PLAN pays 100% for covered services. $200 copay per day to a maximum of $600 per admission, then PLAN pays 70% for covered services, after meeting deductible. ††
Physical, Occupational, and Speech Therapy* PLAN pays 100% for covered services. PLAN pays 70% for covered services, after meeting deductible. ††
60 visits per calendar year for PT,OT or ST or any combination, cumulative in and out-ofnetwork, no pre-authorization required. Additional visits beyond 60 require pre-authorization.
Cardiac Rehabilitation PLAN pays 100% for covered services. PLAN pays 70% for covered services, after meeting deductible. ††
A maximum of 60 visits per calendar year, cumulative in and out-of-network, no pre-authorization required.
Pulmonary Rehabilitation PLAN pays 100% for covered services. PLAN pays 70% for covered services, after meeting deductible. ††
A maximum of 60 visits per calendar year, cumulative in and out-of-network, no preauthorization required.
Chiropractic $35 office visit copay applies. PLAN pays 70% for covered services, after meeting deductible. ††
Maximum of 30 visits per calendar year (cumulative In and Out-of-Network)
Durable Medical Equipment PLAN pays 100% for covered services. (diabetic supplies are excluded, except blood glucose meters, insulin pumps, and tubing). PLAN pays 70% for covered services, after meeting deductible†† (diabetic supplies are excluded, except blood glucose meters, insulin pumps, and tubing)
External Prosthetic Devices PLAN pays 100% for covered services to a maximum of $2000 per calendar year; then PLAN pays 70% for covered services (Maximum does not apply to external breast prostheses). PLAN pays 70% for covered services, after meeting deductible. ††
Behavioral/Mental Health (including Alcohol & Substance Abuse) Inpatient*:
PPO provider: $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.
Non-PPO Provider: $200 copay per day to a maximum of $600 per admission, then
PLAN pays 70% after meeting deductible, for covered services to a maximum of 30 days†
per calendar year. ††

Detoxification*:
PPO provider: $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.
Non-PPO Provider: $200 copay per day to a maximum of $600 per admission, then
PLAN pays 70%, after meeting deductible, for covered services to a maximum of 12 days†
per calendar year. ††

Outpatient:
You may choose PPO or non-PPO providers.
PPO provider: $10 copay; then PLAN pays 100% for covered services.
Non-PPO providers: PLAN pays 70%, after meeting deductible. ††
30 visits per calendar year. †
Intensive Outpatient Program:
$50 copay per program; 3 programs per calendar year; does not count towards 30 outpatient visit
limit. Pre-authorization required. ††
Cost-sharing for behavioral/mental health does not apply to out-of-pocket maximums.
Skilled Nursing Facility* PLAN pays 100% for covered services. PLAN pays 70% for covered services, after meeting deductible, for up to 60 days per calendar year.††
Inpatient Extended Active
Rehabilitation*		 PLAN pays 100% for covered services. PLAN pays 70% for covered services, after meeting deductible, for up to 60 days per calendar year. ††
Home Health Care* PLAN pays 100% for covered services. PLAN pays 70% for covered services, after meeting deductible. ††
Hospice Care PLAN pays 100% for covered services. PLAN pays 70% for covered services, after meeting deductible. ††
Routine Vision Services
 $5 copay for one routine vision exam every 12 months when services received from BCBSAZ in-network 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.
 Not covered
Acupuncture Services * Office copay applies per visit; subject to certain PLAN criteria and limitations. PLAN pays 70% for covered services, after meeting deductible; 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 to a maximum of $2,000 per calendar year for hearing aids, then PLAN pays 70% for covered services. PLAN pays 70% for covered services, after meeting deductible. ††
Contract Maximum Unlimited. $1,000,000 maximum benefit while the contract is in force. All payments by PLAN (for both PPO and non-PPO providers apply toward the contract maximum. ††

*Pre-authroization is required

† Cumulative In and Out-of_Network
†† Member is responsible for the difference between the provider's billed charges and the BCBSAZ allowed amount at non-contracted providers, even after meeting the out-of-pocket maximum.

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