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Blue Cross Select Gold

Calendar Year Deductible $850 individual; $1,700 family
Out-of-Pocket Maximum
$6,000 individual; $12,000 family
Primary Care Select Physician
$35 copay. Each member must designate a Primary Care Select physician.
Specialist Office Visit
$50 copay. You must have a referral from your Primary Care Select physician.
Telephone and Online Video Consultations
You pay $40 per consultation.
Outpatient Surgery
Lower Member Cost Share: $225 copay / Higher Member Cost Share: $450 copay
Emergency Room
$225 hospital copay / $50 doctor copay
Prescription Drugs




Tier 1: $10 copay / Tier 2: $20 copay / Tier 3: $45 copay / Tier 4: You pay a
$90 copay or 40% member coinsurance (whichever is greater) / Tier 5
(preferred specialty): $175 copay / Tier 6 (nonpreferred specialty): You pay
a $250 copay or 20% member coinsurance (whichever is greater) /
Generic drugs are mandatory when available
Notes


This plan uses the Source+Rx 1.0 Prescription Drug List and the
ValueONE Network, which does not include all major retail chains. 
Check the pharmacy network
Pediatric Routine Dental Cleaning and
Yearly Eye Exam

Routine Dental Cleaning: you pay $0; Yearly Eye Exam: you pay 20% after
you meet the calendar year deductible