| In-Network (PPO benefit) - You pay: | Out-of-Network (Non-PPO benefit)* - You pay: | |
|---|---|---|
| Preventive Care | Nothing for covered preventive screenings, immunizations and services | 35% of our allowance† |
| Physician Care | $25 for primary care | 35% of our allowance† |
| Virtual Doctor Visits by Teladoc® | $0 for first 2 visits | N/A |
| Urgent Care Center | Accidental Injury: $0 Medical Emergency: $30 copay | Accidental Injury: $0 Medical Emergency: 35% of our allowance† |
| Prescription Drugs | Preferred Retail Pharmacy: Tier 1 (Generics): $7.50 copay1 Tier 2 (Preferred brand): 30% of our allowance Tier 3 (Non-preferred brand): 50% of our allowance Tier 4 (Preferred specialty): 30% of our allowance Tier 5 (Non-preferred specialty): 30% of our allowance Mail Service Pharmacy: Tier 1 (Generics): $15 copay1 Tier 2 (Preferred brand): $90 copay Tier 3 (Non-preferred brand): $125 copay Specialty Pharmacy2: Tier 4 (Preferred specialty): $65 copay Tier 5 (Non-preferred specialty): $85 copay | Retail Pharmacy: 45% of our allowance Mail Service Pharmacy: Not covered Specialty Pharmacy: Not covered |
| Maternity Care | $0 copay | Pre-/postnatal professional care: 35% of our allowance† Inpatient hospital: $450 per admission copay for unlimited days, plus 35% of our allowance Outpatient facility care: 35% of our allowance† |
| Hospital Care | Inpatient (Precertification is required): $350 per admission Outpatient: 15% of our allowance† | Inpatient (Precertification is required): $450 per admission copay, plus 35% of our allowance Outpatient: 35% of our allowance† |
| Surgery | 15% of our allowance† | 35% of our allowance† |
| ER (accidental injury) | $0 within 72 hours | Nothing for covered services |
| ER (medical emergency) | 15% of our allowance† | 15% of our allowance† |
| Lab work (such as blood tests) | 15% of our allowance† | 35% of our allowance† |
| Diagnostic services (such as sleep studies, X-rays, CT scans) | 15% of our allowance† | 35% of our allowance† |
| Chiropractic Care | $25 per treatment; up to 12 visits per year | 35% of our allowance†; up to 12 visits per year |
| Dental Care | The difference between the fee schedule amount and the Maximum Allowable Charge (MAC) | 35% of our allowance† |
| Rewards Program | Earn $50 for completing the Blue Health Assessment.3 Earn up to $120 for completing three eligible Online Health Coach goals.3 | Earn $50 for completing the Blue Health Assessment.3 Earn up to $120 for completing three eligible Online Health Coach goals.3 |
- Blue Cross Blue Shield Emergency Room Copay Card
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- Bcbs Copay Amount
- Blue Cross Blue Shield Emergency Room Copay Online
Maintenance Notification:
Blue Access for Members and quoting tools will be unavailable from 3am - 6am on Saturday, October 20.
We apologize for any inconvenience.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Note: The cost estimates are based on an approximate grouping of services and reflects2007 HMO cost data trended to Q3 2009. Specificmember experience will vary depending on type, intensity, and number of specificservices. Should I go to the emergency room or urgent care? Who is this for? Blue Cross Blue Shield of Michigan and Blue Care Network members under age 65. What if you get sick or injured and your doctor's office is closed? Understanding your options now can save you time later when you might need immediate care. Beginning January 1, 2017, (and December 24, 2016 for certain members), the hospital Emergency Room (ER) copayment will increase for some of the Horizon Blue Cross Blue Shield of New Jersey plans offered under the State Health Benefits Program (SHBP). New identification cards are not being issued as a result of these ER copayment changes.
Maintenance Notification:
Blue Access for Members and quoting tools will be unavailable from 2am - 5am Saturday, October 20.
We apologize for any inconvenience.
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