Blue Cross Blue Shield of Arizona

Blue AdvanceHealth Gold (4 Free Primary Care In-Person/Virtual Visits)

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Plan Overview

Combined Medical and Drug Deductible	Individual: $4,750.00 Family: $9,500 Per Person: $4,750
Combined Medical and Drug Out of Pocket Maximum	Individual: $4,750.00 Family: $9,500 Per Person: $4,750

Office Visit

Primary Doctor

CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Exclusions: First 4 visits per person per calendar year are covered at no charge. No charge after deductible for additional PCP visits. 24/7 online doctor visits available with BlueCare Anywhere - see SBC for more information.
Benefit Explanation: First 4 visits per person per calendar year are covered at no charge. No charge after deductible for additional PCP visits. 24/7 online doctor visits available with BlueCare Anywhere - see SBC for more information.

Specialist

CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.
Generic Drugs	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Exclusions: Prescription drugs in Tier 1a: New low copays on 30-day supplies of common everyday prescriptions including select insulin. Copays as low as $0 or $3, depending upon your plan. Find out if your prescriptions are on the BCBSAZ Tier1a Drug List at https://azblue.com/pharmacy-management/Tier1a-Drug-List. Prescription drugs in Tier 1b have low copays that range from $5 to $20 on a 30-day supply, depending upon your plan. Excludes medications not on the formulary, unless a formulary exception is approved. Benefit Explanation: Prescription drugs in Tier 1a: New low copays on 30-day supplies of common everyday prescriptions including select insulin. Copays as low as $0 or $3, depending upon your plan. Find out if your prescriptions are on the BCBSAZ Tier1a Drug List at https://azblue.com/pharmacy-management/Tier1a-Drug-List. Prescription drugs in Tier 1b have low copays that range from $5 to $20 on a 30-day supply, depending upon your plan.
Specialty Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the contract holder or covered spouse is confirmed through a court order or legal guardianship.
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year
Benefit Explanation: Limit of 1 routine vision exam per calendar year.

Major Dental Care

Routine Dental Checkups for Children

CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Limit Quantity: 2
Limit Unit : Visit(s) per Year
Benefit Explanation: Limit of 2 dental check-ups & cleanings per year.

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