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Arizona Medical Insurance > BlueCross BlueShield of Arizona > BlueSelect Benefits

BCBSAZ

Quote & Apply - Electronic Application

Except for emergency/accident situations, BlueSelect providers must be used for services to be covered.

BlueSelect Plan Two and Plan Three - HMO PLAN Benefit Summary
 
PLAN TWO
PLAN THREE
Deductible (Calendar-year)
Applies to certain services as listed.   Coinsurance applies after the deductible is met. Copays are not applied toward the deductible.		 None Per person - $1,000

Family - $2,000

Applies to inpatient facility charges.
Coinsurance 1 Coinsurance applies to additional level of coverage on inpatient and outpatient rehabilitation services and skilled nursing facilities. For certain services where indicated, BCBSAZ pays 80%, you pay 20% (80%/20%) of the BCBSAZ allowed amount after meeting deductible, unless a different coinsurance percentage is indicated.
Out-of-Pocket Coinsurance Maximum 1,2 (Calendar-year) A $500 annual out-of-pocket coinsurance maximum per person applies to the additional level of coverage on physical, occupational and speech therapy services. Per person

$3,000 		Family

$6,000
Physician Services – Office Visits3
Primary care physician (PCP) – include internal medicine, family practice, general practice or pediatrics. (All other physicians are specialists)		 PCP: $25 copay

Specialist: $40 copay		 PCP: $25 copay

Specialist: $40 copay
Preventive Care, Mammography, Routine Physical Exams Services provided in the physician’s office are subject to your office visit copay.
Laboratory Services In a physician’s office , applicable office visit copay applies. At contracted, free standing, independent clinical labs, BCBSAZ pays 100% for covered services.
Other Professional Services BCBSAZ pays 100%. Covered services include diagnostic, surgical and anesthesia services rendered outside the physician’s office..
Prescription Medications at Retail and Mail Order Pharmacy4
 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		 Contracted pharmacy
(30-day supply)
Level 1: $ 15 copay
Level 2: $ 40 copay
Level 3: $ 70 copay
Level 4: $ 120 copay		 Mail order
(90-day supply)
Level 1: $ 15 copay
Level 2: $ 80 copay
Level 3: $ 210 copay
Level 4: $ 360 copay
Inpatient Hospital 5 $ 750 copay per admission. Facility charges are subject to deductible and coinsurance.
Outpatient Surgery $200 copay per surgery. You pay the lesser of a $300 copay or the BCBSAZ allowed amount for the facility charge per surgery.
Urgent Care In-state network urgent care centers: $45 copay. In-state network urgent care centers: $50 copay.
Out-of-state: Call (800) 810-BLUE (2583) for assistance in finding the closest BlueCard® Access network provider.  Services obtained through a BlueCard provider will be subject to the applicable urgent care copay.  Services at non-network providers are not covered.
Emergency or Accident $150 access fee (waived if admitted to hospital). $150 access fee (waived if admitted to hospital).
Maternity Inpatient hospital copay per admission. Inpatient hospital deductible and coinsurance apply to facility admissions.
Physician: office visit copay applies only to the first prenatal office visit. Normal prenatal, delivery and postpartum maternity care are covered only if the delivery occurs after the contract has been in force for 12 months. Complications of pregnancy are covered regardless of the delivery date.
Physical, Occupational and Speech Therapy Physical/Occupational Therapy: BCBSAZ pays 100% for covered services for first 80 modalities or therapeutic services per calendar year. Speech therapy: BCBSAZ pays 100% for first 20 visits per calendar year.
After the first 80 modalities or 20 visits, BCBSAZ pays 50%; you pay 50% of the BCBSAZ allowed amount up to the $500 out-of-pocket coinsurance maximum per person per calendar year. After the out-of-pocket coinsurance maximum is met, BCBSAZ pays 100% for the remainder of the calendar year. After the first 80 modalities or 20 visits, BCBSAZ pays 50%; you pay 50% of the BCBSAZ allowed amount up to the out-of-pocket coinsurance maximum per person per calendar year. After the out-of-pocket coinsurance maximum is met, BCBSAZ pays 100% for the remainder of the calendar year.
Chiropractic Services $25 copay. $30 copay.
Up to 12 visits per calendar year available only through the chiropractic services administrator.
Vision Exams (Routine) and Eyewear Discounts $25 copay for one routine eye exam per year 6; discounts on eyewear 6. $30 copay for one routine eye exam per year 6; discounts on eyewear 6..
Ambulance Services BCBSAZ pays 100%.

Behavioral and Mental Health Services 5

Inpatient: up to a maximum benefit for all services (except BSA) of 30 days per person, per calendar-year.

Behavioral health services must be provided and authorized exclusively by the behavioral services administrator 6 (BSA). Outpatient: unlimited psychotherapy and counseling – $15 copay per session.
Inpatient: $750 copay per admission. Inpatient: Facility charges are subject to deductible and coinsurance. Coinsurance paid does not apply to the coinsurance maximum.
Inpatient Rehabilitation Services 5
Both Preferred and nonPreferred admissions count toward the 120-day calendar-year limit.		 BCBSAZ pays 100% for up to 60 days. After 60 days, BCBSAZ pays 50%, you pay 50% up to an additional 60 days. Facility charges: 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 the out-of-pocket coinsurance maximum.
Limited to 120 days per calendar year.
Home Health Services and Home Infusion - Medication Administration Therapy 7 BCBSAZ pays 100%. Certain injectable medications are also available through the specialty injectable medication benefit.
Skilled Nursing Facility 5 BCBSAZ pays 100%, up to 90 days. After 90 days, BCBSAZ pays 50%, you pay 50% up to an additional 90 days. Facility charges: 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 the out-of-pocket coinsurance maximum.
Limited to 180 days per calendar year.
Specialty Self-Injectable Medications through Specialty Pharmacy 5
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)
BCBSAZ pays 100%.

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.
  1. 1 Coinsurance is a percentage you must pay after you have met any applicable calendar-year deductible. Coinsurance is based on the BCBSAZ allowed amount.
  2. The coinsurance maximum is the maximum amount you pay in coinsurance each year before BCBSAZ pays 100 percent of the BCBSAZ allowed amount for covered services. Copays still apply, even if the coinsurance maximum has been reached. 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 physician’s office. No referral from PCP is required by BCBSAZ. Some specialists may still require a referral.
  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 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.

BlueSelect is a Blue Cross Blue Shield of Arizona (BCBSAZ) Health Maintenance Organization (HMO) plan. With BlueSelect, you are not required to have a primary care physician (PCP) direct your care. You do not need a referral to see a specialist or other ancillary provider within the BlueSelect network. However, except for emergencies, all covered services must be provided by BlueSelect network providers. BlueSelect providers will file all claims for you. To see if your physician is in the BlueSelect network, check the provider directory on azblue.com or call BCBSAZ.

While traveling outside of Arizona, the BlueCard® Access program is available when you need urgent care services and/or authorized follow-up care.

  • Contracted providers are independent contractors exercising independent medical judgment and are not employees, agents or representatives of BCBSAZ. BCBSAZ has no control over any diagnosis,
    treatment or service rendered by any provider.
  • BCBSAZ has negotiated various reimbursement methods with contracted providers. These providers have agreed to accept the BCBSAZ allowed amount for covered services provided to BCBSAZ members.  This means that after payment of deductible, coinsurance or copay amounts, these providers will not bill you for the difference between the provider’s billed charges and the BCBSAZ allowed amount for the services. However, when there is another source of payment, such as a liability insurer or government payer, providers may be entitled to collect from the other source or from proceeds received from the other source any difference between the provider’s billed charges and the BCBSAZ allowed amount.
  • Reimbursement is based on the BCBSAZ allowed amount. The BCBSAZ allowed amount is generally calculated using the lesser of billed charges or the applicable BCBSAZ fee schedule, including any
    contractual arrangements.

 

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