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Blue Shield HMO – Silver Access+ HMO 1700/55
Silver Access+ HMO 1700/55 OffEx
In-Network
Annual Deductible
Individual
Family
$1,700
$3,400
Annual Out-of-Pocket Max
Individual
Family
$6,800
$13,600
Office Visit
Primary Provider
$55 copay
Specialist
$85 copay
Preventive Services
No charge
Chiropractic Care
$15 copay
(up to 15 visits per year)
Basic Lab
Basic X-ray
Complex Imaging
(CT Scan, MRI, PET, etc.)
$55 copay per visit
$55 copay per visit
$250 copay per visit (after deductible)
Inpatient Hospitalization
40% after deductible
Outpatient Surgery
Free-Standing Ambulatory Surgery Center
Hospital
40% after deductible
40% after deductible
Urgent Care
$55 copay
Emergency Room
(facility fee)
$275 copay (after deductible)
(copay waived if admitted)
Retail Pharmacy Deductible*
Individual
Family
$275
$550
Tier 1
$15 copay
Tier 2
$55 copay
Tier 3
$75 copay
Tier 4
1
(Excluding Specialty Drugs)
20% up to $250 max per Rx
Supply Limit
Up to 30 days
Mail Order Pharmacy
Tier 1
$30 copay
Tier 2
$110 copay
Tier 3
$150 copay
Tier 4
1
(Excluding Specialty Drugs)
20% up to $500 max per Rx
Supply Limit
Up to 90 days
*Pharmacy Deductible is separate from the Calendar Year Medical Deductible. Does not apply to contraceptive drugs and devices, oral anticancer
medications or Tier 1 drugs. Otherwise applicable to covered drugs in Tiers 2, 3 and 4. Accrues to the calendar year out-of-pocket maximum.
1
Specialty drugs are available from a Network Specialty Pharmacy by mail or upon member request, retail stores for pick up. Blue Shield’s short
cycle Specialty Drug Program allows initial Specialty Drugs to be dispensed in 15-day supply trials.