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Arizona Medical Insurance > BlueCross BlueShield of Arizona > BlueClassic® Benefits

BCBSAZ

Quote & Apply - Electronic Application

BlueClassic® INDEMNITY PLAN Benefit Summary
Deductible (Calendar-year)
Copays are not applied toward the deductible. Deductible must be met for all covered services unless otherwise stated.		 Per person
$250, $500, $750, $1,250, $2,500 and $5,000
Family
$500, $1,000, $1,500, $2,500, $5,000 and $10,000
Coinsurance 1, 2 BCBSAZ pays 80%, you pay 20% (80%/20%) of the BCBSAZ allowed amount for most covered services, after meeting deductible, unless a different coinsurance percentage is indicated.
Out-of-Pocket Coinsurance Maximum 2 (Calendar-year) $5,000 per person
You are still responsible for a noncontracted provider’s billed charges even after the out-of-pocket coinsurance maximum is met.
Physician Services – Office Visits PCP or Specialist: Subject to deductible and coinsurance.
Preventive Care, Mammography, Routine Physical Exams Subject to deductible and coinsurance.
Laboratory Services During an office visit, deductible and coinsurance apply as specified. At contracted, freestanding independent clinical labs, BCBSAZ pays 100% for covered services, deductible waived. At all other facilities 80%/20% after meeting deductible.
Other Professional Services Subject to deductible and coinsurance. Covered services include diagnostic, surgical and anesthesia services rendered outside the physician’s office.
Prescription Medications at Retail and Mail Order Pharmacy3
Expenses do not apply toward any applicable medical benefit plan deductible or out-of-pocket coinsurance maximum. Mail order is only available through the contracted mail order provider.		 $2,500 deductible option: $250 prescription medication deductible per person, per calendar-year
$5,000 deductible option: $500 prescription medication deductible per person, per calendar-year
Contracted pharmacy (30-day supply)
Level 1: $ 15 copay
Level 2: $ 35 copay
Level 3: $ 65 copay
Level 4: $ 120 copay		 Mail order (90-day supply)
Level 1: $ 15 copay
Level 2: $ 70 copay
Level 3: $ 195 copay
Level 4: $ 360 copay
When you fill a prescription at a noncontracted retail pharmacy, in addition to the applicable prescription medication copay and any applicable prescription medication deductible, you are also responsible for the difference between a noncontracted pharmacy’s price and BCBSAZ’s allowed amount. Mail order is not covered through a noncontracted provider.
Inpatient Hospital 4 Subject to deductible and coinsurance.
Outpatient Services
(Facility charges)		 Subject to deductible and coinsurance.
Urgent Care Subject to deductible and coinsurance.
Emergency or Accident $150 access fee (per person, per provider, per day), then subject to deductible and coinsurance. Emergency room access fee is waived if you are admitted to the hospital..
Maternity – Complications of Pregnancy Only Subject to deductible and coinsurance.
Physical, Occupational and Speech Therapy Subject to deductible and coinsurance.
Chiropractic Services Subject to deductible and coinsurance.
Vision Exams (Routine) and Eyewear Discounts Contracted provider: $15 copay. One routine eye exam per person, per calendar-year 5. Discounts on eyewear 5.
Noncontracted provider: Reimbursement up to $25 for one routine exam per year. No eyewear discounts.
Ambulance Services 80%/20%, deductible waived.
Behavioral and Mental Health Services 4
Cost sharing for behavioral/mental health does not apply to any out-of-pocket coinsurance maximum.

Outpatient: You may choose Participating or noncontracted providers or the behavioral services administrator 5  (BSA). BSA: $15 copay for unlimited psychotherapy and counseling, per visit. Participating and Noncontracted Providers: BCBSAZ pays 50%, you pay 50% after meeting deductible with a benefit maximum of 20 psychological sessions per person, per calendar-year.

Inpatient facility: Subject to deductible and coinsurance. Two admissions per person, per calendar-year, up to a combined total of 30 days. Inpatient professional services: 50%/50% after meeting deductible.

$25,000 per person benefit maximum for all services (except from BSA) while the contract is in force.
Inpatient Rehabilitation Services 4 80%/20% after meeting deductible, up to 60 days. After 60 days, BCBSAZ pays 50%, you pay 50% up to an additional 60 days which will not count toward any out-of-pocket coinsurance maximum. Limited to 120 days per person, per calendar-year.
Home Health Services and Home Infusion - Medication Administration Therapy 6 Subject to deductible and coinsurance. Certain injectable medication are also available through the specialty injectable medication benefit.
Skilled Nursing Facility 4 80%/20% after meeting deductible, up to 90 days. After 90 days, BCBSAZ pays 50%, you pay 50% up to an additional 90 days which will not count toward any out-of-pocket coinsurance maximum. Limited to 180 days per person, per calendar-year.
Specialty Self-Injectable Medications 4 through Specialty Pharmacy
For certain specified self-injectable prescription biologic medications. Specialty injectable medications are not covered under the retail or mail order medication benefit. (Also see Home Health.)		 Contracted specialty pharmacy (30-day supply)
Level A: $30 copay
Level B: $ 60 copay
Level C: $90 copay
Level D: $120 copay		 Noncontracted pharmacies are not covered.
Please refer to azblue.com for a listing of specialty self-injectable medications and contracted specialty pharmacies or call BCBSAZ. Injectable medications are also available from home health providers subject to deductible and coinsurance.
Contract Maximum $4,000,000 maximum benefit per person while the contract is in force. All payments by BCBSAZ (for both Participating and noncontracted providers) apply toward the contract maximum.
  1. Coinsurance is a percentage you must pay for covered services after you have met the calendar-year deductible. Coinsurance is based on the BCBSAZ allowed amount.
  2. In addition to any applicable deductible and coinsurance, noncontracted providers may charge you for the difference between their billed charges and the BCBSAZ allowed amount. This obligation to pay the difference between the provider’s billed charges and the BCBSAZ allowed amount continues even after the member’s out-of-pocket coinsurance maximum is met. Deductible, copays, access fees and amounts you pay for noncovered services do not count toward the out-of-pocket coinsurance maximum.
  3. Precertification is required for certain medications covered under the retail and mail order pharmacy benefit. A list of medications that require precertification and the process for obtaining precertification is available on the BCBSAZ Web site at azblue.com or by calling BCBSAZ at (602) 864-4273 or (800) 232-2345, ext. 4273. Otherwise covered eligible medications will not be covered if precertification is not obtained when required.
  4. Precertification is required. If precertification is not obtained, services will be subject to an additional $300 deductible or denial of benefits.
  5. Services are available only in Arizona.
  6. Precertification is required for certain medications provided through the Home Health and Home Infusion - Medication Administration Therapy benefit. A list of medications requiring precertification is available on the BCBSAZ Web site at azblue.com or by calling BCBSAZ at (602) 864-4320 or (800) 232-2345, ext. 4320. Otherwise covered eligible medications will not be covered if precertification is not obtained when required.

 

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