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Blue Cross Select Silver


Calendar Year Deductible $2,800 individual; $5,600 family
Out-of-Pocket Maximum $6,850 individual; $13,700 family
Primary Care Select Physician $40 copay. Each member must designate a Primary Care Select physician.
Specialist Office Visit
$65 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: $350 copay / Higher Member Cost Share:
$700 copay

Emergency Room
$350 hospital copay / $65 doctor copay
Prescription Drugs




Tier 1: $20 copay / Tier 2: $30 copay / Tier 3: $75 copay / Tier 4: You pay a
$125 copay or 50% member coinsurance (whichever is greater) / Tier 5
(preferred specialty): $250 copay/ Tier 6 (nonpreferred specialty): You pay
a $300 copay or 30% 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.