You have the right to view information in your language. I would like to view information in

Plan Details

silver pos

BCBSHP Silver Blue OpenAccess POS 3500/10%

$850.28/mo Monthly Premium:

Plan Cost

$850.28

Network:Blue Open Access POS, Dental Prime, and Rx Choice Tiered Network

Primary Care Visit:$50

Inpatient Hospital Services:$500/Stay + 50% after ded.

Medical & Drug Deductible:$3,500

EHB & Drug OOP Max:$6,500

Annual Deductible
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkCombined
Combined Medical & Drug DeductibleIndividual: $3,500 Family: $7,000Individual: $3,500 Family: $7,000Individual: $10,500 Family: $21,000Individual: Not Applicable Family: Not Applicable
Annual Out-of-Pocket
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkCombined
Out of Pocket Max for Med and Drug EHB Benefits (Total)Individual: $6,500 Family: $13,000Individual: $6,500 Family: $13,000Individual: $19,500 Family: $39,000Individual: Not Applicable Family: Not Applicable
Professional Services
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Other Practitioner Office Visit (Nurse, Physician Assistant)$50Not Applicable40% Coinsurance after deductibleSee Brochure
Imaging (CT/PET Scans, MRIs)$300 then 50% Coinsurance after deductibleNot Applicable$600 then 50% Coinsurance after deductibleExplanation: Cost share is driven by provider/setting.
X-rays and Diagnostic Imaging10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleExplanation: Cost share is driven by provider/setting.
Specialist Visit$75Not Applicable40% Coinsurance after deductibleSee Brochure
Chiropractic Care10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleLimit: 20 Visit(s) per Year Explanation: Visit limit is combined both across outpatient and other professional visits. Cost share is driven by provider/setting.
Laboratory Outpatient and Professional Services10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleExplanation: Cost share is driven by provider/setting.
Primary Care Visit to Treat an Injury or Illness$50Not Applicable40% Coinsurance after deductibleSee Brochure
Prescription Drug Coverage
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Generic Drugs$10$2040% Coinsurance after deductibleExplanation: 30 day retail supply or 90 day mail order. 2.5X copay (if applicable) for mail order.
Preferred Brand Drugs$40$5040% Coinsurance after deductibleExplanation: 30 day retail supply or 90 day mail order. 3X copay (if applicable) for mail order.
Non-Preferred Brand Drugs40% Coinsurance after deductible50% Coinsurance after deductible40% Coinsurance after deductibleExplanation: 30 day retail supply or 90 day mail order
Specialty Drugs 40% Coinsurance after deductible50% Coinsurance after deductible40% Coinsurance after deductibleExclusions: Out of Network mail order pharmacy services and Out of Network Specialty Drugs are not covered. Explanation: 30 day supply only for retail or mail order
Preventative Care
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Well Baby Visits and CareNo ChargeNot Applicable40% Coinsurance after deductibleExplanation: Care provided for birth through age 5.
Preventive Care/Screening/ImmunizationNo ChargeNot Applicable40% Coinsurance after deductibleSee Brochure
Emergency Health
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Urgent Care Centers or Facilities$50 then 10% Coinsurance after deductibleNot Applicable$50 then 10% Coinsurance after deductibleExplanation: Cost share is driven by provider/setting.
Emergency Room Services$500 then 10% Coinsurance after deductibleNot Applicable$500 then 10% Coinsurance after deductibleExplanation: Copayment (if applicable) is waived if admitted.
Emergency Transportation/Ambulance10% Coinsurance after deductibleNot Applicable10% Coinsurance after deductibleExplanation: Benefits for Non-Emergency ambulance services will be limited to $50,000 per occurrence if a Non-Network Provider is used.
Outpatient Services
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Outpatient Surgery Physician/Surgical Services10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleSee Brochure
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleSee Brochure
Outpatient Rehabilitation Services10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleLimit: 20 Visit(s) per Year Explanation: 20 visits for Rehabilitation Speech Therapy and 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy. Certain other therapies may be excluded. Speech Therapy, Occupational
Hospitalization Services
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Inpatient Physician and Surgical Services10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleSee Brochure
Habilitation Services10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleLimit: 20 Visit(s) per Year Explanation: 20 visits for Habilitation Speech Therapy and 20 visits combined for Habilitation Physical Therapy and Occupational Therapy.  Certain other therapies may be excluded.  Speech Therapy, Occupational Therapy and Physi
Inpatient Hospital Services (e.g., Hospital Stay)$500 Copay per Stay then 50% Coinsurance after deductibleNot Applicable$1,000 Copay per Stay then 50% Coinsurance after deductibleSee Brochure
Skilled Nursing Facility10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleLimit: 60 Days per year Explanation: Combined days for Inpatient Rehabilitation and Skilled Nursing Facility services.
Substance Abuse Disorder Outpatient Services10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleExplanation: Cost share is driven by provider/setting.
Substance Abuse Disorder Inpatient Services$500 Copay per Stay then 50% Coinsurance after deductibleNot Applicable$1,000 Copay per Stay then 50% Coinsurance after deductibleSee Brochure
Maternity Care
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Delivery and All Inpatient Services for Maternity Care$500 then 50% Coinsurance after deductibleNot Applicable$1,000 then 50% Coinsurance after deductibleExplanation: Hospital stay is 48 hours for vaginal delivery and 96 hours for c-section
Prenatal and Postnatal Care10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleSee Brochure
Home Health Care
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Home Health Care Services10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleLimit: 120 Visit(s) per Year Explanation: Limit does not apply to Physical, Occupational or Speech Therapy when performed as part of Home Health Care Services.
Other Services
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Cosmetic Surgery$500 then 50% Coinsurance after deductibleNot Applicable$1,000 then 50% Coinsurance after deductibleExplanation: Reconstructive surgery is covered. Reconstructive surgery is performed to correct deformities caused by congenital or developmental abnormalities, illness, injury, or previous therapeutic process, for the purpose of improving bodily function
Mental/Behavioral Health Inpatient Services$500 Copay per Stay then 50% Coinsurance after deductibleNot Applicable$1,000 Copay per Stay then 50% Coinsurance after deductibleSee Brochure
Durable Medical Equipment10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleSee Brochure
Hospice Services10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleSee Brochure
Mental/Behavioral Health Outpatient Services10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleExplanation: Cost share is driven by provider/setting.
Weight Loss Programs$75Not Applicable40% Coinsurance after deductibleLimit: 4 Visit(s) per Year Explanation: Covered only for treatment of morbid obesity. Excluded Nutritional supplements; services, supplies and/or nutritional sustenance products (good). Limited to 4 visits per year.
Rehabilitative Speech Therapy10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleLimit: 20 Visit(s) per Year Explanation: 20 visits for Rehabilitation Speech Therapy.  Certain other therapies may be excluded.  Speech Therapy limits will not apply for children ages 0-6  with Autism (ASD) diagnosis to the service maximums/limits in any
Rehabilitative Occupational and Rehabilitative Physical Therapy10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleLimit: 20 Visit(s) per Year Explanation: 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy.  Certain other therapies may be excluded.  Occupational Therapy and Physical Therapy limits will not apply for childre
Accidental Dental$75Not Applicable40% Coinsurance after deductibleExplanation: Cost share is driven by provider/setting.
Allergy Testing10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleExplanation: Cost share is driven by provider/setting.
Chemotherapy10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleExplanation: Cost share is driven by provider/setting.
Diabetes Education$75Not Applicable40% Coinsurance after deductibleExplanation: Cost share is driven by provider/setting.
Dialysis10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleExplanation: Cost share is driven by provider/setting.
Infusion Therapy10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleExplanation: Cost share is driven by provider/setting.
Nutritional Counseling10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleLimit: 4 Visit(s) per Year Explanation: Covered only for treatment of morbid obesity. Excluded Nutritional supplements; services, supplies and/or nutritional sustenance products (good). Limited to 4 visits per year.
Prosthetic Devices10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleExplanation: Wigs are limited to 1 (one) per year as needed after cancer treatment. 
Radiation10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleExplanation: Cost share is driven by provider/setting.
Reconstructive Surgery$500 then 50% Coinsurance after deductibleNot Applicable$1,000 then 50% Coinsurance after deductibleExplanation: Reconstructive surgery is covered. Reconstructive surgery is performed to correct deformities caused by congenital or developmental abnormalities, illness, injury, or previous therapeutic process, for the purpose of improving bodily function
Transplant$500 then 50% Coinsurance after deductibleNot Applicable$1,000 then 50% Coinsurance after deductibleLimit: 10000 Dollars per Procedure Explanation: Transplant Transportation and Lodging $10,000 Maximum benefit limit per Transplant. Unrelated Donor Search $30,000 Maximum benefit limit per Transplant.
Treatment for Temporomandibular Joint Disorders10% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleSee Brochure
Additional BenefitsClinical Trials: $500 + 50% after ded.Clinical Trials: N/AClinical Trials: $1,000 + 50% after ded.Bone Marrow Transplant: Limit: 10000 Dollars per Procedure Explanation: Transplant Transportation and Lodging $10,000 Maximum benefit limit per Transplant. Unrelated Donor Search $30,000 Maximum benefit limit per Transplant.
Dental
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Dental Check-Up for ChildrenNo Charge after deductibleNot ApplicableNo Charge after deductibleLimit: 2 Visit(s) per Year
Major Dental Care – Child50% Coinsurance after deductibleNot Applicable50% Coinsurance after deductibleSee Brochure
Basic Dental Care – Child40% Coinsurance after deductibleNot Applicable40% Coinsurance after deductibleSee Brochure
Orthodontia – Child50% Coinsurance after deductibleNot Applicable50% Coinsurance after deductibleSee Brochure
Vision
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Routine Eye Exam for ChildrenNo ChargeNot ApplicableNot CoveredLimit: 1 Visit(s) per Year Explanation: Out of network reimbursement up to $30
Eye Glasses for ChildrenNo ChargeNot ApplicableNot CoveredLimit: 1 Item(s) per Year Explanation: Out of network reimbursement up to $25-$55 depending on materials