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Blue Value Gold

Calendar Year Deductible $750 individual; $1,500 Family
Out-of-Pocket Maximum 
$6,000 individual; $12,000 Family
Primary Care Select Physician

$40 copay. Receive a discounted copay of $25 when visiting
your designated Primary Care Select physician.
Specialist Office Visit

$60 copay. Receive a discounted copay of $45 when referred
to a specialist by your designated 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 facility copay / $60 doctor copay
Prescription Drugs




Tier 1: $10 copay / Tier 2: $25 copay / Tier 3: $45 copay / Tier 4: $90 copay
or 40% member coinsurance (whichever is greater) / Tier 5 (preferred
specialty): $175 copay / Tier 6 (nonpreferred specialty): $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