| | | BluePreferred $2,500 | In-Network | Out-Of-Network |  | Annual Deductible | Individual: $2,500 Family: $5,000 | Individual: $3,000 Family: $6,000 | | | Annual Out-Of-Pocket Limit | $3,000 per person (Deductible not Included) | $6,000 per person (Deductible not Included) | | | Lifetime Maximum | $3,000,000 | $3,000,000 | | | Office Visits | PCP $30/Specialist $60 | 40% | | | Prescription Drugs | $15 Level 1 $35 Level 2 $65 Level 3 $120 Level 4 | $15 Level 1 $35 Level 2 $65 Level 3 $120 Level 4 | | | Laboratory and Radiology | 20% | 40% | | | Annual Physical Exam | PCP $30/Specialist $60 | Not Covered | | | Annual OB-GYN Exam | PCP $30/Specialist $60 | Not Covered | | | Prenatal / Postnatal Maternity | Not Applicable | Not Applicable | | | Well Baby Care | PCP $30/Specialist $60 | Not Covered | | | Outpatient Surgery | 20% | 40% | | | Emergency Room | 20% plus $150 (waived if admitted) | 20% plus $150 (waived if admitted) | | | Ambulance | 20% (Deductible Waived) | 20% (Deductible Waived) | | | Home Health Care | 20% (Up to 3 visits of 2 hours or less per day) | 40% (Up to 3 visits of 2 hours or less per day) | | | Mental Health Services | See benefits contract | See benefits contract | | | Chiropractic Care | $60 | $40 | | | Acupuncture / Acupressure | Not Covered | Not Covered | | | Inpatient Co-payment | 20% | 40% | | | Maternity Care | Not Covered | Not Covered | | | Inpatient Mental Health | 20% (2 admissions, up to a combined total of 30 days. $25,000 maximum benefit) | 50% (2 admissions, up to a combined total of 30 days. $25,000 maximum benefit) | | | Chemical Dependency | See benefits contract | See benefits contract | | |
QUOTE APPLY ONLINE DOWNLOAD APPLICATION DOCTOR SEARCH PLAN BENEFITS PDF EXCLUSIONS
| | | | About Blue Cross Blue Shield of Arizona Blue Cross Blue Shield of Arizona, an independent licensee of the Blue Cross Blue Shield Association, is a local not-for profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,500 dedicated employees throughout its Phoenix, Tucson, Tempe and Flagstaff offices. The company provides health insurance products, services or networks to more than 1.1 million individuals, making it the largest locally based insurance company in Arizona. Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. As an active supporter of the community, Blue Cross Blue Shield supports more than 200 organizations statewide through volunteering and contributions. | | | | |
