March 20, 2010

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Blue Cross Blue Shield of Arizona – BlueOptimum – ARIZONA

A comparison of the BlueOptimum offered by Blue Cross Blue Shield of Arizona is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Copay
  • Primary Care Physician: $25 copay
  • Specialist: $50 copay
    		•
  • Primary Care Physician: 60% after deductible
  • Specialist: 60% after deductible
    		•
    Office Visit
  • Primary Care Physician: $25 copay
  • Specialist: $50 copay
    		•
  • Primary Care Physician: 60% after deductible
  • Specialist: 60% after deductible
    		•
    Deductible Individual: $5,000, Family: $10,000 Individual: $5,500, Family: $11,000
    Coinsurance 80% after deductible 60% after deductible
    Coinsurance Limit $2,500 per member $5,000 per member
    Out-of-Pocket Maximum $2,500 per member $5,000 per member
    Lifetime Maximum $5,000,000 maximum benefit per member while the benefit plan is in force $5,000,000 maximum benefit per member while the benefit plan is in force
    Prescription Drugs Prescription Medications at Retail and Mail Order Pharmacy:
  • $250 prescription deductible per member, per calendar year, for Level 2, 3, and 4 prescription medicationsRetail pharmacy:
    • Level 1: $15 copay
    • Level 2: $35 copay
    • Level 3: $65 copay
    • Level 4: $120 copay
    Mail order:
    • Level 1: $15 copay
    • Level 2: $70 copay
    • Level 3: $195 copay
    • Level 4: $360 copay
    		•  Prescription Medications at Retail and Mail Order Pharmacy:
  • $250 prescription deductible per member, per calendar year, for Level 2, 3, and 4 prescription medicationsRetail pharmacy:
    • Level 1: $15 copay
    • Level 2: $35 copay
    • Level 3: $65 copay
    • Level 4: $120 copay
    Mail order:
    • Level 1: $15 copay
    • Level 2: $70 copay
    • Level 3: $195 copay
    • Level 4: $360 copay
    		•
    Emergency Room
  • Emergency: $150 access fee per member, per provider, per day, then BCBSAZ pays 80% after deductible (emergency room access fee is waived if you are admitted to the hospital)
  • Ambulance Services: 80%, deductible waived
    		•
  • Emergency: $150 access fee per member, per provider, per day, then BCBSAZ pays 80% after deductible (emergency room access fee is waived if you are admitted to the hospital)
  • Ambulance Services: 80%, deductible waived
    		•
    Adult Preventative Care Preventive Services (Certain Screening Services, Immunizations, Routine Physicals, Mammography):
    • Primary Care Physician: $25 copay
    • Specialist: $50 copay
  • 80% for covered services provided outside the physician's office(deductible does not apply to covered preventive services)
    		•  BlueOptimum
    Child Preventative Care BlueOptimum BlueOptimum
    Lab / X-Ray Laboratory Services (Deductible and coinsurance apply to services rendered by pathologists):
    • In a physician's office: 100%; office visit copay waived, if the only services you receive during your visit are laboratory services
    • At contracted, freestanding, independent clinical labs: 100%, deductible and coinsurance waived
    • At all other facilities: 80% after deductible
    		 Laboratory Services (Deductible and coinsurance apply to services rendered by pathologists): 60% after deductible
    Maternity Maternity - Complications of Pregnancy Only: 80% after deductible Maternity - Complications of Pregnancy Only: 60% after deductible
    Physical Therapy
  • Physical, Occupational and Speech Therapy: 80% after deductible
  • Chiropractic: $50 copay per member, per provider, per day for most covered services performed in a chiropractor's office; 80% after deductible for other covered services, such a physical therapy
    		•
  • Physical, Occupational and Speech Therapy: 60% after deductible
  • Chiropractic: 60% after deductible
    		•
    Skilled Nursing 80% after deductible, for up to 90 days; After 90 days, BCBSAZ pays 50% up to an additional 90 days which will not count toward any out-of-pocket coinsurance maximum (Coverage is limited to 180 days per member, per calendar year) 60% after deductible, for up to 90 days; After 90 days, BCBSAZ pays 50% up to an additional 90 days which will not count toward any out-of-pocket coinsurance maximum (Coverage is limited to 180 days per member, per calendar year)
    Home Health Care 80% after deductible 60% after deductible
    Mental Health Behavioral and Mental Health Services:
  • Outpatient: You may choose in-network or out-of-network providers or the behavioral services administrator (BSA)
    • BSA: $15 copay per visit for psychotherapy and counseling
    • In-network and out-of-network providers: 50% after deductible, with a maximum of 20 psychological sessions per member, per calendar year
  • Inpatient: Two admissions per member, per calendar year, up to a combined total of 30 days
    • In-network facility: 80% after deductible
    • Inpatient professional services: 50% after deductible
  • $25,000 per member plan maximum for all services (except from BSA)
    		•  Behavioral and Mental Health Services:
  • Outpatient: You may choose in-network or out-of-network providers or the behavioral services administrator (BSA)
    • BSA: $15 copay per visit for psychotherapy and counseling
    • In-network and out-of-network providers: 50% after deductible, with a maximum of 20 psychological sessions per member, per calendar year
  • Inpatient: Two admissions per member, per calendar year, up to a combined total of 30 days
    • Out-of-network facility: 50% after deductible
    • Inpatient professional services: 50% after deductible
  • $25,000 per member plan maximum for all services (except from BSA)
    		•
    Hospital Care
  • Inpatient Hospital: 80% after deductible
  • Outpatient Services: 80% after deductible
    		•
  • Inpatient Hospital: 60% after deductible
  • Outpatient Services: 60% after deductible
    		•
    Optional Benefits BlueOptimum BlueOptimum