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Blue Value Silver

Calendar Year Deductible $2,600 individual; $5,200 family
Out-of-Pocket Maximum
$6,850 individual; $13,700 family
Primary Care Select Physician
$50 copay. Receive a discounted copay of $40 when visiting your
designated Primary Care Select physician
Specialist Office Visit

$65 copay. Receive a discounted copay of $55 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: $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