|Blue Choice $25 Copay Option Benefit Summary
||Referrals NOT required effective 1/1/2011
||$250 hospital copayment
$200 physician surgical copayment
||$50 hospital copayment
$40 physician copayment
|Emergency Room Care for Emergency Medical Conditions
||$25 PCP copayment
$40 Specialist copayment
|Sick Child Visits
|Well Child Visits
||Covered in full
|Preventive Dental for Children
||$40 copayment, once every 2 years; every year for children up to age 19
||$60 allowance, once every 2 years; every year for children up to age 19
||Tier 1: $10 copayment
Tier 2: $30 copayment
Tier 3: $50 copayment
For each 30 day supply.
Includes oral contraceptives.
|Out of Network Benefits
||Emergency services only
||Discounts available through Member Rewards
This summary is not a contract or binding agreement. It reflects many commonly held benefits for this plan. Benefits will be different for members of certain employer groups. For details about your specific coverage, ask your employer or contact Member Services by email or by calling the number on your member ID card.
To be covered, all services must be medically necessary for the diagnosis and treatment of your condition, covered by your insurance contract, approved by the Medical Director, and performed, prescribed or authorized in advance by your Primary Care Physician.