Blue Cross Blue Shield of Arizona

Blue AdvanceHealth Silver Neighborhood (4 Free Visits with PCP)

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Combined Medical and Drug Deductible	Individual: $6,600.00 Family: $13200 Per Person: $6600
Combined Medical and Drug Out of Pocket Maximum	Individual: $6,600.00 Family: $13200 Per Person: $6600

Primary Doctor

CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Exclusions: Free PCP virtual visits exclude visits with BlueCare Anywhere providers and only apply to telehealth visits with the member's PCP.
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

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: Excludes medications not on the formulary, unless a formulary exception is approved. Benefit Explanation: Prescription drugs in Tier 1a: Low copays on 30-day supplies of common everyday prescriptions including select insulin. Find out if your prescriptions are on the BCBSAZ Tier1a Drug List at https://azblue.com/pharmacy-management/Tier1a-Drug-List.?
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.

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

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 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

Routine Eye Exams for Children

Routine Dental Checkups for Children