** SilverSneakers and the SilverSneakers shoe logotype are registered trademarks of Tivity Health, Inc. © Tivity Health, Inc. All rights reserved.

1. Blue Cross Blue Shield Of Alabama
2. Blue Cross Blue Shield Of Alabama Urgent Care Copay
3. What Is The Copay For Blue Cross Blue Shield
4. Blue Cross Blue Shield Medicare Advantage

^* TruHearing is an independent company offering exclusive hearing aid savings for Blue Cross and Blue Shield of Alabama members. For Routine Hearing Exams and Hearing Aids services, you must see a TruHearing provider to use these benefits. Please call 1-855-541-6179 to locate a TruHearing provider and to schedule an appointment.

Blue Advantage Complete (PPO) H0104-014 is a 2020 Medicare Advantage Plan or Medicare Part-C plan by Blue Cross and Blue Shield of Alabama available to residents in Alabama. This plan includes additional Medicare prescription drug (Part-D) coverage. Blue Cross and Blue Shield of Alabama Prepared to Meet the Needs of Customers In the Event of Sustained Spread of COVID-19. Birmingham, AL – Blue Cross and Blue Shield of Alabama cares first and foremost about the health and well-being of our customers. Please be assured Blue Cross will continue to meet the needs of groups, members and providers with the sustained spread of a novel coronavirus. Recent tornadoes have caused widespread damage and adversely affected many Blue Cross and Blue Shield of Alabama members. If you have been affected by these tornadoes and have questions, you can call customer service at 1-855-745-0831. A Medicare Supplement from Blue Cross and Blue Shield of Alabama will help you with the copayments, coinsurance, and deductibles, making your costs more manageable. Blue Cross and Blue Shield of Alabama offers 1 different lettered plans, each with its own pros and cons.

^*** Glucometer and test strip brands include Ascensia (CONTOUR™NEXT & PLUS) and LifeScan (OneTouch®).

This information is not a complete description of benefits. Call 1-855-828-3982 (TTY 711)* for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. The Formulary, pharmacy network, and/or provider networ may change at any time. You will receive notice when necessary. To the extent of any discrepancy between this web site and your Evidence of Coverage/Contract Booklet, your Evidence of Coverage/Contract Booklet takes priority.

Reset Plans

Blue
Choice®
Platinum for Business

Blue
Access® Gold
for Business

Blue
Secure Gold
for Business

Blue
Secure Silver
for Business

Blue
HSA Silver
for Business

Blue
Saver® Bronze
for Business

Materials
Calendar Year Deductible

$100

$200

$600

$1,200

$1,200

$2,400

$4,000

$8,000

$4,000

$8,000

$7,750

$15,500

Out-of-Pocket

SELF-ONLY

FAMILY

$4,000

$8,000

$6,000

$12,000

$6,750

$13,000

$8,550

$17,100

$6,000

$12,000

$7,750

$15,500

Office Visit Copay

$20 Primary Care/
$30 Specialist

$30 Primary Care/
$50 Specialist

$35 Primary Care/
$60 Specialist

$40 Primary Care/
$70 Specialist

Plan pays 80% after Deductible

$40 copay for 1st three illness related office visits; thereafter plan pays 100% after Deductible

Telephone and Online Video Consultation

Blue Cross Blue Shield Of Alabama

Available through Teladoc

$20 payment per consultation

$30 payment per consultation

$35 payment per consultation

$40 payment per consultation

Plan pays 0% after a $45 payment per consultation

$45 per consultation

Inpatient
Hospital

Plan pays 100% after $150 daily copay days 1 - 5 for each admission

Lower Member
Cost Share:
Plan pays 100% after $250 daily copay days 1-5 for each admission
Higher Member
Cost Share:
Plan pays 100% after $500 daily copay days 1-5 for each admission

Lower Member
Cost Share:
Plan pays 100% after $300 daily copay days 1-5 for each admission
Higher Member
Cost Share:
Plan pays 100% after $600 daily copay days 1-5 for each admission

Lower Member
Cost Share:
Plan pays 100% after $450 daily copay days 1-5 for each admission
Higher Member
Cost Share:
Plan pays 100% after $850 daily copay days 1-5 for each admission

Plan pays 80%
after Deductible

Plan pays 100%
after Deductible

Outpatient
Surgery

Plan pays 100% after $150 hospital copay

Lower Member
Cost Share:
Plan pays 100% after $250 hospital copay
Higher Member
Cost Share:
Plan pays 100% after $500 hospital copay

Lower Member
Cost Share:
Plan pays 100% after $300 hospital copay
Higher Member
Cost Share:
Plan pays 100% after $600 hospital copay

Lower Member
Cost Share:
Plan pays 100% after $450 hospital copay
Higher Member
Cost Share:
Plan pays 100% after $850 hospital copay

Plan pays 80%
after Deductible

Plan pays 100%
after Deductible

ER Visit

Plan pays 100% after $150 hospital copay

Plan pays 100% after $250 hospital copay

Plan pays 100% after $300 hospital copay

Plan pays 100% after $450 hospital copay

Plan pays 80%
after Deductible

Plan pays 100%
after Deductible

Prescription Drugs (per 30-day supply)
Tier 1
$10 copay
Tier 2
$20 copay
Tier 3
$35 copay
Tier 4
$75 copay
Tier 5
$100 copay
Tier 6
$200 copay
Tier 1
$10 copay
Tier 2
$20 copay
Tier 3
$40 copay
Tier 4
$80 copay
Tier 5
$125 copay
Tier 6
$250 copay
Tier 1
$10 copay
Tier 2
$20 copay
Tier 3
$50 copay
Tier 4
$90 copay
Tier 5
$200 copay
Tier 6
$300 copay
Tier 1
$15 copay
Tier 2
$30 copay
Tier 3
$75 copay
Tier 4
$100 copay
Tier 5
$250 copay
Tier 6
Plan pays 60%
Tier 1 - Tier 6
Plan pays 80%
after Deductible

Blue Cross Blue Shield Of Alabama Urgent Care Copay

Tier 1
$20 copay
Tier 2
$35 copay
Tier 3 - Tier 6
Plan pays 100% after DeductibleMail Order Pharmacy
Tier 1
$25 copay
Tier 2
$50 copay
Tier 3
$87.50 copay
Tier 4
$187.50 copay
Tier 5
not covered
Tier 6
not covered
Tier 1
$25 copay
Tier 2
$50 copay
Tier 3
$100 copay
Tier 4
$200 copay
Tier 5
not covered
Tier 6
not covered
Tier 1
$25 copay
Tier 2
$50 copay
Tier 3
$125 copay
Tier 4
$225 copay
Tier 5
not covered
Tier 6
not covered
Tier 1
$37.50 copay
Tier 2
$75 copay
Tier 3
$187.50 copay
Tier 4
$250 copay
Tier 5
not covered
Tier 6
not covered
N/A
N/AValueONE Pharmacy Network

x

x

x

x

x

x

Source+Rx 2.0 Formulary

x

x

x

Source+Rx 1.0 formulary

x

x

x

Pediatric Vision

Plan pays 80%
after Deductible

Plan pays 80%
after Deductible

Plan pays 80%
after Deductible

Plan pays 80%
after Deductible

Plan pays 80%
after Deductible

Plan pays 100%
after Deductible

Pediatric Dental

DIAGNOSTIC & PREVENTIVE

BASIC SERVICES

MAJOR SERVICES

MEDICALLY NECESSARY ORTHODONTIA

Plan pays 100%

Plan pays 80%

Plan pays 50%
after Deductible

Plan pays 50%
after Deductible

Plan pays 100%

Plan pays 80%

Plan pays 50%
after Deductible

Plan pays 50%
after Deductible

Plan pays 100%

Plan pays 80%

Plan pays 50%
after Deductible

Plan pays 50%
after Deductible

Plan pays 100%

What Is The Copay For Blue Cross Blue Shield

Plan pays 80%

Plan pays 50%
after Deductible

Blue Cross Blue Shield Medicare Advantage

Plan pays 50%
after Deductible

Plan pays 100%
after Deductible

Plan pays 80%
after Deductible

Plan pays 50%
after Deductible

Plan pays 50%
after Deductible

Plan pays 100%

Plan pays 100%

Plan pays 100%
after Deductible

Plan pays 100%
after Deductible