Capital Blue Cross - Catastrophic PPO 8700/0/0
Primary Care Visit
First 4 visits at $0 Copay
50% Coinsurance after deductible
Specialist Visit
No Charge after deductible
50% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
No Charge after deductible
50% Coinsurance after deductible
Preventive Care/Screening/Immunization
No Charge
50% Coinsurance after deductible
Laboratory Outpatient and Professional Services
No Charge after deductible
50% Coinsurance after deductible
X-rays and Diagnostic Imaging
No Charge after deductible
50% Coinsurance after deductible
Imaging (CT/PET scans, MRIs)
No Charge after deductible
50% Coinsurance after deductible
Generic Drugs
No Charge after deductible
No Charge after deductible
Preferred Brand Drugs
No Charge after deductible
No Charge after deductible
Non-Preferred Brand Drugs
No Charge after deductible
No Charge after deductible
Specialty drugs
No Charge after deductible
100% Coinsurance
Outpatient Facility Fee
No Charge after deductible
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
No Charge after deductible
50% Coinsurance after deductible
Emergency Room Services
No Charge after deductible
No Charge after deductible
Emergency Transportation/Ambulance
No Charge after deductible
No Charge after deductible
Urgent Care
No Charge after deductible
No Charge after deductible
Inpatient Hospital Services
No Charge after deductible
50% Coinsurance after deductible
Inpatient Physician and Surgical Services
No Charge after deductible
50% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
No Charge after deductible
50% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
No Charge after deductible
50% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
No Charge after deductible
50% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
No Charge after deductible
50% Coinsurance after deductible
Prenatal and postnatal care
No Charge after deductible
50% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
No Charge after deductible
50% Coinsurance after deductible
Home Healthcare Services
No Charge after deductible
50% Coinsurance after deductible
Outpatient Rehabilitation Services
No Charge after deductible
50% Coinsurance after deductible
Habilitation Services
No Charge after deductible
50% Coinsurance after deductible
Skilled Nursing Facility
No Charge after deductible
50% Coinsurance after deductible
Durable Medical Equipment
No Charge after deductible
100% Coinsurance
Hospice Services
No Charge after deductible
50% Coinsurance after deductible
Chiropractic Care
No Charge after deductible
50% Coinsurance after deductible
Acupuncture
No Charge after deductible
50% Coinsurance after deductible
Rehabilitative Speech Therapy
No Charge after deductible
50% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
No Charge after deductible
50% Coinsurance after deductible
Well Baby Visits and Care
No Charge
50% Coinsurance after deductible
Allergy Testing
No Charge after deductible
50% Coinsurance after deductible
Diabetes Education
No Charge after deductible
50% Coinsurance after deductible
Nutritional Counseling
No Charge after deductible
50% Coinsurance after deductible
Eye Exam for Children
No Charge
70% Coinsurance
Eye Glasses for Children
No Charge
70% Coinsurance
Accidental Dental
No Charge after deductible
50% Coinsurance after deductible
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
50% Coinsurance after deductible
70% Coinsurance after deductible
Dental Check Up (Child)
No Charge
20% Coinsurance
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
50% Coinsurance after deductible
70% Coinsurance after deductible
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
50% Coinsurance after deductible
100% Coinsurance
Routine Dental Services (Adult)
Not covered
Not covered