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

BCBSAZ

Quote & Apply - Electronic Application

BlueClassic® Saver INDEMNITY PLAN Benefit Summary
Deductible (Calendar-year)
Deductible must be met for all covered services..		 Per person
$5,000
Family
$10,000
After Deductible is Met: BCBSAZ pays 100%, of the BCBSAZ allowed amount. You are still responsible for any balance bill from a noncontracted provider.
Out-of-Pocket Coinsurance Maximum(Calendar-year) $5,000 per person / $10,000 per family
The out-of-pocket maximum is a maximum liability and is based on the BCBSAZ allowed amount rather than a provider’s billed charges. Amounts paid for noncovered services and noncontracted providers’ balance bills, do not count toward satisfaction of the maximum. Even after reaching the maximum, you remain responsible for noncontracted providers’ balance bills (the difference between a noncontracted provider’s billed charges and the BCBSAZ allowed amount).
Physician Services – Office Visits BCBSAZ pays 100% after meeting deductible.
Preventive Care, Mammography, Routine Physical Exams BCBSAZ pays 100% after meeting deductible.
Laboratory Services BCBSAZ pays 100% after meeting deductible..
Other Professional Services BCBSAZ pays 100% after meeting deductible. Covered services include diagnostic, surgical and anesthesia services rendered outside the physician’s office.
Prescription Medications at Retail and Mail Order Pharmacy1
BCBSAZ places limits, including but not limited to, quantity, age and gender, for certain prescription medications as indicated in the prescription medication guide, available online at azblue.com or by calling BCBSAZ.		 BCBSAZ pays 100% after meeting deductible.
Payment for mail order must be made with a debit or credit card and is only available through the contracted mail order provider. Mail order is not covered through a noncontracted provider.
Inpatient Hospital 2 BCBSAZ pays 100% after meeting deductible.
Outpatient Services
(Facility charges)		 BCBSAZ pays 100% after meeting deductible.
Urgent Care BCBSAZ pays 100% after meeting deductible.
Emergency or Accident $150 access feeper visit, then BCBSAZ pays 100% after meeting deductible; emergency room access fee is waived if you are admitted to the hospital.
Maternity – Complications of Pregnancy Only BCBSAZ pays 100% after meeting deductible.
Physical, Occupational and Speech Therapy BCBSAZ pays 100% after meeting deductible.
Chiropractic Services BCBSAZ pays 100% after meeting deductible.
Vision Exams (Routine) and Eyewear Discounts Contracted provider:One routine eye exam per person per calendar year; discounts on eyewear. BCBSAZ pays 100% after meeting deductible..

Noncontracted provider: Reimbursement up to $25 for one routine exam per year. No eyewear discounts.
Ambulance Services BCBSAZ pays 100% after meeting deductible.
Behavioral and Mental Health Services 2
Cost sharing for behavioral/mental health does not apply to any out-of-pocket coinsurance maximum.

Outpatient: BCBSAZ pays 100% after meeting deductible with a maximum of 20 psychological sessions per person, per calendar year.

Inpatient:  BCBSAZ pays 100% after meeting deductible. Two admissions per calendar year, up to a combined total of 30 days.

$25,000 per person benefit maximum for all services while the contract is in force.
Home Health Services and Home Infusion - Medication Administration Therapy 6 BCBSAZ pays 100% after meeting deductible. Certain injectable medication are also available through the specialty injectable medication benefit.
Skilled Nursing Facility 2 BCBSAZ pays 100% after meeting deductible. Limited to 180 days per person, per calendar-year.
Inpatient Rehabilitation Services 2 BCBSAZ pays 100% after meeting deductible. Limited to 120 days per person, per calendar-year.
Specialty Self-Injectable Medications 1 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
BCBSAZ pays 100% after meeting deductible.		 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 $5,000,000 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. Precertification is required for certain medications including all specialty self-injectable medications. Lists 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.
  2. Precertification is required. If precertification is not obtained, medications or services will be subject to an additional $300 deductible or denial of benefits.

 

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