Blue Cross Copay
| Basic Option | |
|---|---|
| Preventive Care | Nothing for covered preventive screenings, immunizations and services |
| Physician Care | $30 for primary care1 |
| Virtual doctor visits by Teladoc® | $0 for first 2 visits |
| Urgent Care Center | $35 copay |
| Prescription Drugs | Preferred Retail Pharmacy: Tier 1 (Generics): $10 copay Tier 2 (Preferred brand): $55 copay2 Tier 3 (Non-preferred brand): 60% of our allowance ($75 minimum)2 Tier 4 (Preferred specialty): $65 copay2 Tier 5 (Non-preferred specialty): $90 copay2 Mail Service Pharmacy: Available to members with Medicare Part B primary only. Visit the Medicare page for more information. Tier 1 (Generics): $20 Tier 2 (Preferred brand): $100 copay Tier 3 (Non-preferred brand): $125 copay Specialty Pharmacy: Tier 4 (Preferred specialty): $85 copay2 Tier 5 (Non-preferred specialty): $110 copay2 |
| Maternity Care | $175 inpatient $0 outpatient |
| Hospital Care | Inpatient (Precertification is required): $175 per day; up to $875 per admission Outpatient: $100 per day per facility1 |
| Surgery | $150 in an office setting1 $200 in a non-office setting1 |
| ER (accidental injury) | $175 per day per facility |
| ER (medical emergency) | $175 per day per facility |
| Lab work (such as blood tests) | $0 copay1 |
| Diagnostic services (such as sleep studies, CT scans) | Up to $100 in an office1 Up to $150 in a hospital1 |
| Chiropractic Care | $30 per treatment; up to 20 visits per year |
| Dental Care | $30 copay per evaluation; up to 2 per year |
| Rewards Program | Earn $50 for completing the Blue Health Assessment3 Earn up to $120 for completing three eligible Online Health Coach goals3 |
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association MEDICAL PLAN BALANCE 2000 SILVER HERITAGE SIGNATURE AND DENTAL CHOICE IN-NETWORK OUT-OF-NETWORK Mental Health Office Visit (Unlimited) $70 Copay Specialist and non designated PCP, applies to the $8,150 Out of Pocket Maximum. As a Blue Cross Blue Shield of Michigan member, you get discounted prices on covered prescription drugs. By using your Blue Cross ID card, you will beneit from the lowest possible price at a network pharmacy, even if the pharmacy sells a medication for less. Eliminating copays makes it easier for seniors to get the care they need. –Blue Cross and Blue Shield of North Carolina (Blue Cross NC) announced today it is waiving all copays for in-network primary care and outpatient behavioral health visits for Medicare Advantage members from June 1 through the end of 2020.
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