Blue Cross Blue Shield of Arizona

Blue Portfolio HSA Bronze (Free Preventive Care)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $7,000.00 Family: $14,000 Per Person: $7,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,000.00 Family: $14,000 Per Person: $7,000

Office Visit

Primary Doctor	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Exclusions: 24/7 online doctor visits available with BlueCare Anywhere - see SBC for more information. Benefit Explanation: 24/7 online doctor visits available with BlueCare Anywhere - see SBC for more information.
Specialist	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.
Generic Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.
Specialty Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the contract holder or covered spouse is confirmed through a court order or legal guardianship.
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year
Benefit Explanation: Limit of 1 routine vision exam per calendar year.

Major Dental Care

Routine Dental Checkups for Children

CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Limit Quantity: 2
Limit Unit : Visit(s) per Year
Benefit Explanation: Limit of 2 dental check-ups & cleanings per year.

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