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

BCBSAZ

Quote & Apply - Electronic Application

BluePreferred® - PPO PLAN Benefit Summary
 
PREFERRED PROVIDER (PPO)
IN-NETWORK
NONPREFERRED PROVIDER (NonPPO)
OUT-OF-NETWORK
Deductible (Calendar-year)
Copays and access fees are not applied toward the deductible. Preferred deductibles are accumulated separately from  nonPreferred deductibles. Deductibles must be met for all covered services unless otherwise stated.		 Per person
$250, $500, $1,000, $2,500 and $5,000
Family
$500, $1,000, $2,000, $5,000 and $10,000		 Per person
$750, $1,000, $1,500, $3,000 and $5,500
Family
$1,500, $2,000, $3,000, $6,000 and $11,000
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. BCBSAZ pays 60%, you pay 40% (60%/40%) 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)
The Preferred out-of-pocket  coinsurance maximum is accumulated separately from the nonPreferred out-of-pocket coinsurance maximum.		 Deductible options
$250. $500, $1000
$2,500
$5,000 		Per person
$2,500
$3,000
$4,000		 Deductible options
$250. $500, $1000
$2,500
$5,000 		Per person
$5,500
$6,000
$8,000
You are still responsible for a noncontracted provider’s billed charges even after the out-of-pocket coinsurance maximum is met.
Physician Services – Office Visits3
Deductible option determines PCP copay. Primary care physician (PCP) - include internal medicine, family practice, general practice or pediatrics. (All other physicians are specialists.)		 Deductible
$250
$500
$1,000
$2,500
$5,000
 PCP Copay
$15
$20
$25
$30
$35
 Specialist Copay
$30
$40
$50
$60
$70		 60%/40% after meeting deductible.
Preventive Care, Mammography, Routine Physical Exams Services provided in the physician’s office are subject to the office visit copay 3.  Services provided outside the physician’s office are subject to coinsurance. Not covered except for routine mammograms.  Routine mammography: 60%/40%.
The deductible does not apply to covered preventive care services.
Laboratory Services In a physician’s office, applicable office visit copay applies. At contracted, freestanding independent clinical labs, BCBSAZ pays 100% for covered services,
deductible waived. At all other facilities, 80%/20% after meeting deductible.		 60%/40% after meeting deductible.
Other Professional Services 80%/20% after meeting deductible. 60%/40% after meeting deductible.
Covered services include diagnostic, surgical and anesthesia services rendered outside the physician’s office.
Prescription Medications at Retail and Mail Order Pharmacy4
Mail order is only available through the Preferred mail order provider.		 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, 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 5 80%/20% after meeting deductible. 60%/40% after meeting deductible.
Outpatient Services
(Facility charges)		 80%/20% after meeting deductible. 60%/40% after meeting deductible.
Urgent Care Deductible
$250
$500
$1,000
$2,500
$5,000		 Copay
$35
$40
$50
$60
$70		 60%/40% after meeting deductible.
Emergency or Accident $150 access fee (per person, per provider, per day), then BCBSAZ pays 80%, you pay 20% after meeting deductible; emergency room access fee is waived if you are admitted to the hospital.
Maternity – Complications of Pregnancy Only 80%/20% after meeting deductible. 60%/40% after meeting deductible.
Physical, Occupational and Speech Therapy 80%/20% after meeting deductible. 60%/40% after meeting deductible.
Chiropractic Services 80%/20% after meeting deductible. 60%/40% after meeting deductible.
Vision Exams (Routine) and Eyewear Discounts Deductible
$250
$500
$1,000
$2,500
$5,000		 Routine Vision Exam copay
$15
$20
$25
$30
$35		 Reimbursement up to $25 for one routine eye 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.

Both Preferred and nonPreferred
admissions count toward the
2-admissions, 30-day limit.

Outpatient: You may choose Participating or noncontracted providers or the behavioral services administrator 5  (BSA). BSA: $15 copay
Preferred and NonPreferred 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: Two admissions per person, per calendar-year, up to a combined total of 30 days.
Preferred facility: 80%/20% after meeting deductible. NonPreferred facility: 50%/50% after meeting deductible.
Preferred and NonPreferred 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 5
Both Preferred and nonPreferred admissions count toward the 120-day calendar-year limit.		 80%/20% after meeting deductible, for 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. 60%/40% 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 calendar year.
Home Health Services and Home Infusion - Medication Administration Therapy 7 80%/20% after meeting deductible. Certain injectable medications are also available through the specialty injectable medication benefit. 60%/40% after meeting deductible.
Skilled Nursing Facility 5 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. 60%/40% 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 calendar year.
Specialty Self-Injectable Medications 5 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

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.

 Not Covered (see Home Health).
Contract Maximum $3,000,000 maximum benefit per person while the contract is in force. All payments by BCBSAZ (for both Preferred
and nonPreferred 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. You will pay a higher coinsurance percentage when using a nonPreferred provider. 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 maximum is met. Copays, access fees and deductibles are not applied toward the out-of-pocket coinsurance maximum.
  3. Only one copay per person, per provider, per day for most covered services performed in a PCP’s office.
  4. 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.
  5. Precertification is required. If precertification is not obtained, services will be subject to an additional $300 deductible or denial of benefits.
  6. Services are available only in Arizona.
  7. 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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