Blue Cross myBlueCare PA

Plan Information
Company Blue Cross of Northeastern Pennsylvania
State PA
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) $1,000 $6,000
Deductible (Family) $2,000 $12,000
Coinsurance 10% 50%
Out of Pocket Maximum (Individual) $4,500 $10,000
Out of Pocket Maximum (Family) $9,000 $20,000
Services In Network Out of Network
Primary Care Visit $15 50% coinsurance
Specialist Visit $40 50% coinsurance
In Patient Hospital Services 10% Coinsurance after deductible 50% coinsurance
Emergency Room Services $100 $100 copay
Mental / Behavioral Health 10% coinsurance 50% coinsurance
Imaging (CT/PET Scans, MRIs) $75 copay 50% coinsurance
Rehabilitative Speech Therapy 10% coinsurance 50% coinsurance
Rehabilitative Occupational & Physical Therapy 10% coinsurance 50% coinsurance
Preventative Care $0 50% coinsurance
Laboratory Outpatient and Professional Services 10% coinsurance 50% coinsurance
X-ray and Diagnostic Imaging 10% coinsurance 50% coinsurance
Prescription Drugs In Network Out of Network
Generic Rx $30
Preferred Brand Rx $90
Non Preferred Brand Rx $150
Specialty Drugs $150

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) $750.00
Deductible (Family) $1,500.00
Out of Pocket Maximum (Individual) $3,500.00
Out of Pocket Maximum (Family) $7,000.00
Services In Network Out of Network
Primary Care Physician $15
Specialists $40
Emergency Room $100
Inpatient Facility 10% Coinsurance after deductible
Inpatient Physician 10% Coinsurance after deductible
Prescription Drugs In Network Out of Network
Generic Rx $30.00
Preferred Brand Rx $90
Non Preferred Brand Rx $150
Specialty Drugs $150

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) $400.00
Deductible (Family) $800.00
Out of Pocket Maximum (Individual) $500.00
Out of Pocket Maximum (Family) $1,000.00
Services In Network Out of Network
Primary Care Physician $15
Specialists $40
Emergency Room $100
Inpatient Facility 10% Coinsurance after deductible
Inpatient Physician 10% Coinsurance after deductible
Prescription Drugs In Network Out of Network
Generic Rx $30.00
Preferred Brand Rx $90
Non Preferred Brand Rx $150
Specialty Drugs $150

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) $100.00
Deductible (Family) $200.00
Out of Pocket Maximum (Individual) $200.00
Out of Pocket Maximum (Family) $400.00
Services In Network Out of Network
Primary Care Physician $15
Specialists $40
Emergency Room $100
Inpatient Facility 10% Coinsurance after deductible
Inpatient Physician 10% Coinsurance after deductible
Prescription Drugs In Network Out of Network
Generic Rx $30.00
Preferred Brand Rx $90
Non Preferred Brand Rx $150
Specialty Drugs $150

Other Plans

Other plans that are available in the state.

Plan Name
my Blue Cross $2000, a Multi-State Plan
my Blue Cross $2500, a Multi-State Plan
myBlue Access $1,500
myBlue Access $500
myBlue Access $6,350
myBlue Access $750
myBlue Accesss LP $4,500
myBlue Choice $1,000
myBlue Choice $2,500
myBlue Choice $250
myBlue Choice LP $5,500
myBlueCare
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