Blue Saver Silver

Calendar Year Deductible $3,500 individual; $7,000 family
Out-of-Pocket Maximum
$8,150 individual; $16,300 family
Primary Care Select Physician


$50 copay; Each member must designate a Primary Care Select physician
Specialist Office Visit
$75 copay. You must have a referral from your Primary Care Select physician
Telephone and Online Video Consultations
You pay $45 per consultation
Outpatient Surgery 25% member coinsurance, after meeting the calendar year deductible
Emergency Room 25% member coinsurance, after meeting the calendar year deductible
Prescription Drugs Tier 1: $20 copay / Tier 2: $30 copay / Tiers 3-6: 25% member coinsurance, after meeting the calendar year deductible
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: 25% member coinsurance, after meeting the calendar year deductible
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