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Blue Standardized Gold – Neighborhood Network

53901AZ1420126
Gold
HMO

Blue Standardized Gold – Neighborhood Network is a Gold HMO plan by Blue Cross Blue Shield of Arizona.

IMPORTANT: You are viewing the 2023 version of Blue Standardized Gold – Neighborhood Network 53901AZ1420126. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Blue Standardized Gold – Neighborhood Network is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Blue Standardized Gold – Neighborhood Network 53901AZ1420126.
Insurer: Blue Cross Blue Shield of Arizona
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 53901AZ1420126

Cost-Sharing Overview

Blue Standardized Gold – Neighborhood Network offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Blue Standardized Gold - Neighborhood Network?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Blue Standardized Gold – Neighborhood Network offers the following features and referral requirements.

Wellness Program: No
Disease Program:
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: You must select a network PCP and notify BCBSAZ of your selection. PCP referral required for all Specialists except OB/GYN, Chiropractors, Outpatient Behavioral Health providers, Physical Therapy, Occupational Therapy, Speech Therapy, Cognitive Therapy (PT, OT, ST, CT) and Cardiac and Pulmonary Rehabilitative and Habilitative Services, Pediatric Dental and Vision services, Telehealth and Urgent Care services, Walk-in Clinics, and Emergency services.
Plan Exclusions: Non-covered services and any services related to or associated with non-covered services, non-medically necessary services, and all other benefit specific and general exclusions and limitations listed in the benefit book. This exclusion does not apply to services required by federal or state law to be covered.
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Blue Standardized Gold – Neighborhood Network covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergencies Only. Authorization required for non-emergent services.
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergencies, Urgent Care and Authorized Follow-up Care. Urgent Care and Authorized Follow-up Care covered only through contracted providers.
National Network: No

Additional Benefits and Cost-Sharing

Blue Standardized Gold – Neighborhood Network includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 100.00% PCP visits with non-designated PCP are not covered. 24/7 online doctor visits available with BlueCare Anywhere – see SBC for more information.
Specialist Visit
Covered
$60.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
25.00% Coinsurance after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
No Charge No Charge 100.00% Excludes respite care. The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Covered
25.00% Coinsurance after deductible 100.00% Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Custodial Nursing is not covered by the Plan.
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$45.00 100.00%
Home Health Care Services
Covered
25.00% Coinsurance after deductible 100.00%42 Visit(s) per Year Excludes respite care, custodial care, private duty nursing. 1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3. The home health agency delivering care must be certified within the state the care is received.; 4. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
$1000.00 Copay with deductible 25.00% Coinsurance after deductible 100.00% The following bariatric surgery procedures are covered: open roux-en-y gastric bypass (RYGBP), laparoscopic roux-en-y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), open biliopancreatic diversion with duodenal switch (BPD/DS), laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS), and laparoscopic sleeve gastrectomy (LSG) 1. The patient must have a body-mass index (BMI) greater than equal to 35.; 2. Have at least one co-morbidity related to obesity.; 3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient’s medical record: Active participation within the last two years in one physician?supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of all of the following components: a. Weight; b. Current dietary program; c. Physical activity (e.g., exercise program); 4. In addition, the procedure must be performed at an approved BlueDistinction facility for bariatric surgery; 5. The member must be 18 years or older, or have reached full expected skeletal growth.
Cosmetic Surgery
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 100.00%90 Days per Year 90 combined SNF and inpatient extended rehabilitation days per calendar year.
Prenatal and Postnatal Care
Covered
$60.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 100.00% Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the contract holder or covered spouse is confirmed through a court order or legal guardianship.
Mental/Behavioral Health Outpatient Services
Covered
$30.00 100.00% Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs.
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00% Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs.
Substance Abuse Disorder Outpatient Services
Covered
$30.00 100.00% Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs.
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00% Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs.
Generic Drugs
Covered
$15.00 100.00% Excludes medications not on the formulary, unless a formulary exception is approved.
Preferred Brand Drugs
Covered
$30.00 100.00% Excludes medications not on the formulary, unless a formulary exception is approved.
Non-Preferred Brand Drugs
Covered
$60.00 100.00% Excludes medications not on the formulary, unless a formulary exception is approved.
Specialty Drugs
Covered
$250.00 100.00% Excludes medications not on the formulary, unless a formulary exception is approved.
Outpatient Rehabilitation Services
Covered
25.00% Coinsurance after deductible 100.00%60 Visit(s) per Year Visit limit is separate from habilitation service limit. Excludes group therapy, private duty nursing, and custodial care. Short-term rehabilitative therapy includes services in an outpatient facility or physician?s office that is part of a rehabilitation program. These services may include physical, speech, occupational, cardiac rehabilitation, cognitive and pulmonary rehabilitation therapy. Some services may be subject to copay instead of coinsurance. Visit limit is for all therapy types combined.
Habilitation Services
Covered
25.00% Coinsurance after deductible 100.00%60 Visit(s) per Year Visit limit is separate from outpatient habilitation service limit. Excludes group therapy, private duty nursing, and custodial care. Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical, speech, occupational, cardiac, cognitive and pulmonary habilitation therapy for people with disabilities in a variety of inpatient and/or outpatient settings.
Chiropractic Care
Covered
$60.00 100.00%20 Visit(s) per Year HMOs may limit chiropractic visits to 20.
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 100.00% Benefits are limited to one (1) manual or electric (not hospital grade) breast pump and breast pump supplies per member, per calendar year. Benefits are limited to one (1) set of new and four (4) replacement sets of compression garments for the treatment of lymphedema per member, per calendar year. Benefits are limited to one (1) wig and one (1) hairpiece per member, per calendar year.
Hearing Aids
Covered
25.00% Coinsurance after deductible 100.00%1 Item(s) per Benefit Period Excludes disposable hearing aids, ear molds, batteries or battery replacements for hearing aids other than cochlear implants. Hearing aid devices limited to one per ear, per Calendar Year when determined to be medically necessary by the Medical Management Organization.
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 100.00% 0
Preventive Care/Screening/Immunization
Covered
0.00% 100.00%1 Exam(s) per Year Benefits are limited to one (1) preventive physical exam per member, per calendar year, unless additional visits are necessary for the member to obtain all covered Preventive Services.
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
$30.00 100.00%1 Visit(s) per Year Limit of 1 routine vision exam per calendar year.
Eye Glasses for Children
Covered
No Charge No Charge 100.00%1 Item(s) per Year Limit of 1 pair of glasses or contact lenses per calendar year.
Dental Check-Up for Children
Covered
No Charge 100.00%2 Visit(s) per Year Limit of 2 dental check-ups & cleanings per calendar year.
Rehabilitative Speech Therapy
Covered
$30.00 100.00%60 Visit(s) per Year Excludes group therapy, private duty nursing, and custodial care. Visit limit is for multiple therapy types combined (PT, OT, ST, CT and Cardiac and Pulmonary Rehabilitative Visits).
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 100.00%60 Visit(s) per Year Excludes group therapy, private duty nursing, and custodial care. Visit limit is for multiple therapy types combined (PT, OT, ST, CT and Cardiac and Pulmonary Rehabilitative Visits).
Well Baby Visits and Care
Covered
No Charge 100.00% Well Child visits and immunizations are covered as recommended by the American Academy of Pediatrics.
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Covered
50.00% Coinsurance after deductible 100.00%
Orthodontia – Child
Covered
50.00% Coinsurance after deductible 100.00%
Major Dental Care – Child
Covered
50.00% Coinsurance after deductible 100.00%
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
25.00% Coinsurance after deductible 100.00% Travel & lodging expenses are limited to $10,000 per transplant. Travel and lodging are not covered if the Member is a donor. Organ transplant services include the recipient’s medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Transplant services are covered only if they are required to perform human to human organ or tissue transplants, such as:1. Allogeneic bone marrow/stem cell;2. Autologous bone marrow/stem cell;3. Cornea;4. Heart;5. Heart/lung;6. Kidney;7. Kidney/pancreas;8. Liver;9. Lung;10. Pancreas;11. Small bowel/liver; or 12. Kidney/liver. Organ transplant coverage will apply only to non-experimental transplants for the specific diagnosis. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary.
Accidental Dental
Covered
25.00% Coinsurance after deductible 100.00% Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident.
Dialysis
Covered
25.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
$60.00 100.00%
Chemotherapy
Covered
25.00% Coinsurance after deductible 100.00%
Radiation
Covered
25.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
No Charge No Charge 100.00%
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 100.00% Excludes biomechanical devices (external prosthetic device operated through or in conjunction with nerve conduction or other electrical impulses). The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns. External prosthetic appliances shall include artificial arms and legs, wigs, hair pieces and terminal devices such as a hand or hook. Wigs and hair pieces are limited to one per Plan Year. Members must provide a valid prescription verifying diagnosis of alopecia as a result of chemotherapy, radiation therapy, second or third degree burns with a submitted claim for coverage. All other diagnosis are excluded. Replacement of artificial arms and legs and terminal devices are covered only if necessitated by normal anatomical growth or as a result of wear and tear.
Infusion Therapy
Covered
25.00% Coinsurance after deductible 100.00% Infusion/IV Therapy in an Outpatient setting including, but not limited to: Inflixima/b (Remicade), Alefacept (Amevive), and Etanercept (Enbrel).
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 100.00% Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder.
Nutritional Counseling
Covered
No Charge No Charge 100.00% Covered when dietary adjustment has a therapeutic role of a diagnosed chronic disease/condition, including but not limited to:1. Morbid obesity 2. Diabetes 3. Cardiovascular disease 4. Hypertension 5. Kidney disease 6. Eating disorders 7. Gastrointestinal disorders 8. Food allergies 9. Hyperlipidemia
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 100.00% Excludes cosmetic surgery and services except for breast reconstruction following medically necessary mastectomy. Following a mastectomy, the following services and supplies are covered:1. Surgical services for reconstruction of the breast on which the mastectomy was performed; 2. Surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance; 3. Post-operative breast prostheses; and 4. Mastectomy bras/camisoles and external prosthetics that meet external prosthetic placement needs. During all stages of mastectomy, treatments of physical complications, including lymphedema, are covered. Cosmetic Surgery is covered for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury. and any other services required by law. Issuer covers reconstruction of congenital defects and birth abnormalities in accordance with its medical coverage guidelines and/or when required by applicable law. Issuer covers medically necessary complications of breast implants / pectoral implants.
Gender Affirming Care

Free Preventive Services

There is no copayment or coinsurance for any of the following Blue Standardized Gold – Neighborhood Network preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Blue Standardized Gold – Neighborhood Network including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Blue Standardized Gold - Neighborhood Network?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Table of Contents