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my Blue Access PPO Gold 1500
Plan Summary
Plan Type PPO
Metal Level Gold
Office Visit for Primary Doctor
Find Doctors 		$35 Copay
Office Visit for Specialist $35 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $35 Copay
Annual Deductible Individual: $1,500
Separate Prescription Drugs Deductible $0 per person | $0 per group
Coinsurance 30%
Retail Prescription Drugs Generic Drugs: $0 Copay;
Preferred Brand Drugs: $30 Copay;
Non-Preferred Brand Drugs: $150 Copay;
Specialty Drugs: 50% Coinsurance;
Annual Out-of-Pocket Limit Individual: $8,300
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage Yes. Coverage is provided through the Blue Cross Blue Shield Global Core when a Member requires Emergency Care Services or Urgent Care Services while traveling or living outside the United States. All Emergency Care Services and Urgent Care Services are covered in accordance within the Member's Agreement. 
Office Visit
Primary Care Physician Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room $350 Copay
Emergency Ambulance Services 30% Coinsurance after deductible
Urgent Care Facility $70 Copay
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $0 Copay;
Preferred Brand Drugs: $30 Copay;
Non-Preferred Brand Drugs: $150 Copay;
Specialty Drugs: 50% Coinsurance;
Separate Prescription Drugs Deductible $0 per person | $0 per group
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Outpatient Surgery Physician/Surgical Services:
$600 Copay
Outpatient Facility Fee:
$600 Copay
Outpatient Lab/X-Ray Outpatient Lab:
$40 Copay
X-rays:
$40 Copay
Imaging (CT and PET scans, MRIs) 30% Coinsurance after deductible
Outpatient Mental Health $35 Copay
Outpatient Substance Abuse $35 Copay
Outpatient Rehabilitation Services (PT, OT, ST) $35 Copay
Inpatient Coverage
Hospitalization Inpatient Hospital Services:
$725 Copay per Stay after deductible
Inpatient Physician and Surgical Services:
No Charge after deductible
Skilled Nursing Facility $725 Copay per Stay after deductible, limited to 120 Days per Benefit Period
Inpatient Mental Health $725 Copay per Stay after deductible
Inpatient Substance Abuse $725 Copay per Stay after deductible
Home Healthcare 30% Coinsurance after deductible, limited to 60 Visit(s) per Benefit Period
Maternity Coverage
Pre & Postnatal Office Visit No Charge after deductible
Labor & Delivery Hospital Stay $725 Copay after deductible
Pediatric Services
Dental Checkup for Children No Charge, limited to 1 Exam(s) per 6 Months
Vision Screening for Children No Charge, limited to 1 Exam(s) per Year
Eye Glasses for Children No Charge, limited to 1 Item(s) per Year
Major Dental Coverage (Pediatric) 50% Coinsurance
Additional Coverage
Chiropractic Coverage $35 Copay, limited to 20 Visit(s) per Benefit Period
Durable Medical Equipment 30% Coinsurance after deductible
Hospice 30% Coinsurance after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required No
Out-of-Network Annual Deductible $3000 per person | $6000 per group
Out-of-Network Annual Coinsurance 50%
Out-of-Network Annual Out-of-Pocket Limit $16600 per person | $33200 per group
Additional Information
A.M. Best Rating A as of 11/20/2024
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.