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In Network
Out of Network
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In Network
Out of Network
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In Network
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Enroll Now
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Enroll Now
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Enroll Now
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Monthly Premium |
$0 |
$19 |
$0 |
Deductible |
$0 |
$0 |
NA |
Maximum Out-of-Pocket (MOOP) |
$6,600
$11,300 (combined)
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$5,900
$11,300 (combined)
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$6,000 |
True Out-of-Pocket (TrOOP) |
$7,050
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$7,050
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$7,050
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Primary Care Physician Office Visits - in person and telehealth |
$0
$5
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$0
$5
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$0 |
Specialty Office Visit - in person and telehealth |
$40
$40
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$30
$30
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$30 |
Urgent Care |
$50
$50
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$50
$50
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$35 |
Inpatient Hospital Stay |
$300 copay per stay
$300 copay per stay
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$275 copay per stay
$275 copay per stay
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$190 copay per stay
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Ambulatory Surgical Center (ASC) |
$300 copay per stay
$300 copay per stay
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$225 copay per stay
$225 copay per stay
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$250 copay per stay
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Outpatient Surgery |
$315 copay per stay
$315 copay per stay
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$275 copay per stay
$275 copay per stay
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$300 copay per stay
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Emergency Care - copayment waived if admitted |
$90 copay
$90 copay
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$90 copay
$90 copay
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$90 copay
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Labs |
$0 routine monitoring $25 all other
20% coinsurance
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$0 routine monitoring $25 all other
20% coinsurance
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$0 routine monitoring $25 all other
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X-rays |
$25 copay
20% coinsurance
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$50 copay
20% coinsurance
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$50 copay
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Diagnostic Radiology - not including x-rays |
$250 copay
20% coinsurance
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$205 copay per visit
20% coinsurance
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$250 copay
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Diabetes Self-Monitoring Training and Supplies |
$0 copay
20% coinsurance
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$0 copay
20% coinsurance
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$0 copay
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Hearing Services |
$0 copay
50% coinsurance
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$0 copay
50% coinsurance
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$0 copay
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For 1 routine hearing exam/year 1 fitting every 3 years
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For 1 routine hearing exam/year 1 fitting every 3 years
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For 1 routine hearing exam/year 1 fitting every 3 years
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$400 hearing aid allowance both ears combined every 3 years
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$800 hearing aid allowance both ears combined every 3 years
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$800 hearing aid allowance both ears combined every 3 years
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Routine Vision Services |
$0 copay
50% coinsurance
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$0 copay
50% coinsurance
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$0 copay
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1 routine exam per year
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1 routine exam per year
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1 routine exam per year
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Eyewear (eyeglass lens, eyeglass frame, or contacts) |
$125 max allowance every year
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$125 max allowance every year
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$125 max allowance every year
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For eyeglasses frames or contact lenses
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For eyeglasses frames or contact lenses
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For eyeglasses frames or contact lenses
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Routine Dental Services |
$0 copay
50% coinsurance
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$0 copay
50% coinsurance
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$0 copay
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Includes oral exam, and set bitewing x-rays - 2 visits per year
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Comprehensive Dental Services |
$2,000 Maximum allowance/year
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50% coinsurance includes:
Teeth Fillings - Amalgam & Composite
Simple Extractions only
Restorative Services:
Endodontics (Crowns, Inlays, Onlays)
Prosthodontics (Dentures, Bridges, Partials)
Palliative Emergency Treatments
Adjustments and Repairs of Prosthetic
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SilverSneakers® Fitness Benefit |
$0 copay
$0 copay
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$0 copay
$0 copay
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$0 copay
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Durable Medical Equipment |
20% coinsurance
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20% coinsurance
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20% coinsurance
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Over-the-counter |
$30 OTC allowance per month Retail or Mail-order
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$30 OTC allowance per month Retail or Mail-order
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$30 OTC allowance per month Retail or Mail-order
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Transportation Benefit |
$0 copay
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$0 copay
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$0 copay
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Limit 8 trips per calendar year
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Limit 24 trips per calendar year
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Limit 12 trips per calendar year
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Medical Nutritional Therapy |
$0 copay
50% coinsurance
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$0 copay
50% coinsurance
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$0 copay
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Nutritional/Dietary Benefit |
$0 copay
50% coinsurance
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$0 copay
50% coinsurance
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$0 copay
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Virtual Care |
$0 copay, unlimited visits with Capital Blue Cross Virtual Care
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Health Education |
$0 copay 3-30 minutes sessions with Capital Blue Cross Health Coaches
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Prescription Drug Benefits |
$0 Deductible
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Tier 1 - Preferred Generic Drugs |
30 day |
Prf $8 / Stnd $15 |
60 day |
Prf $16 / Stnd $30 |
90 day |
Prf $24 / Stnd $45 |
|
30 day |
Prf $0 / Stnd $15 |
60 day |
Prf $0 / Stnd $30 |
90 day |
Prf $0 / Stnd $45 |
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30 day |
Prf $0 / Stnd $7 |
60 day |
Prf $0 / Stnd $14 |
90 day |
Prf $0 / Stnd $21 |
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Tier 2 - Generic Drugs |
30 day |
Prf $12 / Stnd $20 |
60 day |
Prf $24 / Stnd $40 |
90 day |
Prf $36 / Stnd $60 |
|
30 day |
Prf $0 / Stnd $20 |
60 day |
Prf $0 / Stnd $40 |
90 day |
Prf $0 / Stnd $60 |
|
30 day |
Prf $5 / Stnd $15 |
60 day |
Prf $10 / Stnd $30 |
90 day |
Prf $15 / Stnd $45 |
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Tier 3 - Preferred Brand Drugs |
30 day |
Prf $40 / Stnd $47 |
60 day |
Prf $80 / Stnd $94 |
90 day |
Prf $120 / Stnd $141 |
|
30 day |
Prf $40 / Stnd $47 |
60 day |
Prf $80 / Stnd $94 |
90 day |
Prf $120 / Stnd $141 |
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30 day |
Prf $40 / Stnd $47 |
60 day |
Prf $80 / Stnd $94 |
90 day |
Prf $120 / Stnd $141 |
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Tier 4 - Non-Preferred Drugs |
30 day |
Prf $93 / Stnd $100 |
60 day |
Prf $186 / Stnd $200 |
90 day |
Prf $279 / Stnd $300 |
|
30 day |
Prf $93 / Stnd $100 |
60 day |
Prf $186 / Stnd $200 |
90 day |
Prf $279 / Stnd $300 |
|
30 day |
Prf $93 / Stnd $100 |
60 day |
Prf $186 / Stnd $200 |
90 day |
Prf $279 / Stnd $300 |
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Tier 5 - Specialty Drugs |
30 day ONLY 33% coins
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30 day ONLY 33% coins
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30 day ONLY 33% coins
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Tier 6 - Select Care Drugs |
30 day |
Prf $0 / Stnd $7 |
60 day |
Prf $0 / Stnd $14 |
90 day |
Prf $0 / Stnd $21 |
|
30 day |
Prf $0 / Stnd $7 |
60 day |
Prf $0 / Stnd $14 |
90 day |
Prf $0 / Stnd $21 |
|
30 day |
Prf $0 / Stnd $7 |
60 day |
Prf $0 / Stnd $14 |
90 day |
Prf $0 / Stnd $21 |
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Part D Senior Savings Model - Insulin |
30 day |
Prf $5 / Stnd $5 |
60 day |
Prf $10 / Stnd $10 |
90 day |
Prf $15 / Stnd $15 |
|
30 day |
Prf $5 / Stnd $5 |
60 day |
Prf $10 / Stnd $10 |
90 day |
Prf $15 / Stnd $15 |
|
30 day |
Prf $5 / Stnd $5 |
60 day |
Prf $10 / Stnd $10 |
90 day |
Prf $15 / Stnd $15 |
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Initial Coverage Limit |
$4,430
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$4,430
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$4,430
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Coverage Gap (Donut Hole) |
|
|
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Generics |
25% coinsurance
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25% coinsurance
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25% coinsurance
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Brand Drugs |
25% coinsurance
|
25% coinsurance
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25% coinsurance
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Catastrophic Coverage |
Greater of:
$3.95 - generic/multi source |
$9.85 - all other drugs |
5% coinsurance |
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Greater of:
$3.95 - generic/multi source |
$9.85 - all other drugs |
5% coinsurance |
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Greater of:
$3.95 - generic/multi source |
$9.85 - all other drugs |
5% coinsurance |
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Enroll Now
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Enroll Now
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Enroll Now
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Other ways to enroll
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Other ways to enroll
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Other ways to enroll
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SilverSneakers® is a program of Tivity Health. On behalf of Capital Blue Cross, Tivity Health assists in the administration of this fitness program. Tivity Health is an independent company.
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