Blue Cross Blue Shield CopayComplete Alliance (Maricopa) 40 AZ

Plan Information
Company Blue Cross Blue Shield of Arizona, Inc.
State AZ
Metal Tier Silver
Plan Type PPO

Cost Sharing Benefits

These details are for the standard Silver plan. For reduced Cost Sharing versions scroll down below

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $0 $5,000
Deductible (Family) $0 $10,000
Coinsurance $0 50%
Out of Pocket Maximum (Individual) $6,350 $12,700
Out of Pocket Maximum (Family) $12,700 $25,400
Services In Network Out of Network
Primary Care Visit $40 50% coinsurance
Specialist Visit $80 50% coinsurance
In Patient Hospital Services $1000 Copay per Day 50% coinsurance
Emergency Room Services $500 $500 copay
Mental / Behavioral Health $80 copay 50% coinsurance
Imaging (CT/PET Scans, MRIs) $500 copay 50% coinsurance
Rehabilitative Speech Therapy $80 copay 50% coinsurance
Rehabilitative Occupational & Physical Therapy $80 copay 50% coinsurance
Preventative Care $0 50% coinsurance
Laboratory Outpatient and Professional Services $40 copay 50% coinsurance
X-ray and Diagnostic Imaging $40 copay 50% coinsurance
Prescription Drugs In Network Out of Network
Generic Rx $25
Preferred Brand Rx $70
Non Preferred Brand Rx $160
Specialty Drugs 50%

73% Cost Sharing Benefits

Households with incomes between 200% to 250% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $0.00
Deductible (Family) $0.00
Out of Pocket Maximum (Individual) $5,200.00
Out of Pocket Maximum (Family) $10,400.00
Services In Network Out of Network
Primary Care Physician $40
Specialists $80
Emergency Room $500
Inpatient Facility $1000 Copay per Day
Inpatient Physician No Charge
Prescription Drugs In Network Out of Network
Generic Rx $20.00
Preferred Brand Rx $70
Non Preferred Brand Rx $150
Specialty Drugs 50%

87% Cost Sharing Benefits

Households with incomes between 150% to 200% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $0.00
Deductible (Family) $0.00
Out of Pocket Maximum (Individual) $2,250.00
Out of Pocket Maximum (Family) $4,500.00
Services In Network Out of Network
Primary Care Physician $15
Specialists $30
Emergency Room $250
Inpatient Facility $500 Copay per Stay
Inpatient Physician No Charge
Prescription Drugs In Network Out of Network
Generic Rx $10.00
Preferred Brand Rx $40
Non Preferred Brand Rx $80
Specialty Drugs 50%

94% Cost Sharing Benefits

Households with incomes between 138% to 150% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $0.00
Deductible (Family) $0.00
Out of Pocket Maximum (Individual) $2,250.0
Out of Pocket Maximum (Family) $4,500.00
Services In Network Out of Network
Primary Care Physician $5
Specialists $10
Emergency Room $100
Inpatient Facility $250 Copay per Stay
Inpatient Physician No Charge
Prescription Drugs In Network Out of Network
Generic Rx $5.00
Preferred Brand Rx $10
Non Preferred Brand Rx $15
Specialty Drugs 50%

Other Plans

Other plans that are available in the state.

Plan Name
CopayComplete 20
CopayComplete 40
CopayComplete Alliance (Maricopa) 20
CopayComplete Alliance (Maricopa) 40
CopayComplete Select (Maricopa) 20
CopayComplete Select (Maricopa) 40
Essential 1500
Essential 3000
Essential 4000
Essential 6000
EverydayHealth 1000
EverydayHealth 3000
EverydayHealth 4000
EverydayHealth 6000
EverydayHealth Alliance (Maricopa) 1000
EverydayHealth Alliance (Maricopa) 3000
EverydayHealth Alliance (Maricopa) 4000
EverydayHealth Alliance (Maricopa) 6000
EverydayHealth Select (Maricopa) 1000
EverydayHealth Select (Maricopa) 3000
EverydayHealth Select (Maricopa) 4000
EverydayHealth Select (Maricopa) 6000
FitRewards 1500
FitRewards 3000
FitRewards 4000
FitRewards 6000
Portfolio 1500
Portfolio 2500
Portfolio 3500
Portfolio 5500
SimpleHealth
SimpleHealth (Maricopa) Alliance
SimpleHealth (Maricopa) Select
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This tool is for research purposes only. The numbers shown are estimates based on the information you have provided and our best efforts to provide accurate data. We try to keep the information up to date however we cannot make warranties about the accuracy of our information. We advise that users confirm any research with the respective health insurance companies and health exchanges.