Includes therapeutic radiology services, diagnostic radiology services, diagnostic procedures and tests, surgical and splinting supplies, and lab services.
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How To Receive
Details on how to apply
Obtain a provider order for specific diagnostic testing.
Contact the AZ Blue BlueJourney Team at 1-800-446-8331 (TTY 711) for prior authorization.
The prescribing provider may help with authorization.
Schedule the procedure(s) at the facility selected by the provider.
It is likely that the scheduling department of that facility will reach out to schedule the testing.
The scheduling facility may also help with prior authorization.
Attend the appointment and complete the testing.
Upon receiving results, engage in recommended follow-up and/or referrals.
Copayments and coinsurance
IN-NETWORK
$0 copayment for most x-rays and ultrasounds except as specified below.
20% coinsurance per visit for radiation therapy.
$25 copayment for each carotid or peripheral vascular ultrasound.
$200 copayment for CT, MRI, MRA, and SPECT scans.
$250 copayment for PET scans. 20% coinsurance for virtual capsule enteroscopy.
0% coinsurance for electrocardiogram (EKG).
20% coinsurance for genetic testing.
20% coinsurance for supplies.
$0 copayment for laboratory tests.
$30 copayment per visit for pain management assessment.
$75 copayment per visit for pain management treatment.
$20 copayment per visit to a Wound Care Clinic.
$75 copayment for a sleep study.
20% coinsurance per visit for EECP and TTT treatments.
$25 copayment per visit for hyperbaric oxygen treatment.
OUT-OF-NETWORK
40% coinsurance for most x-rays and ultrasounds except as specified below.
40% coinsurance per visit for radiation therapy.
40% coinsurance for each carotid and peripheral vascular ultrasound.
40% coinsurance for CT, MRI, MRA, and SPECT scans.
40% coinsurance for PET scans.
40% coinsurance for virtual capsule enteroscopy.
40% coinsurance for electrocardiogram (EKG).
40% coinsurance for genetic testing.
40% coinsurance for supplies.
40% coinsurance for laboratory tests.
40% coinsurance per visit for pain management assessment.
40% coinsurance per visit for pain management treatment.
40% coinsurance per visit to a Wound Care Clinic.
40% coinsurance for a sleep study.
40% coinsurance per visit for EECP and TTT treatments.
40% coinsurance per visit for hyperbaric oxygen treatment.
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Covered services include, but are not limited to:
X-rays
Radiation (radium and isotope) therapy, including technician materials and supplies
Surgical supplies, such as dressings
Splints, casts, and other devices used to reduce fractures and dislocations
Laboratory tests
Blood - including storage and administration*
Other outpatient diagnostic tests
*Coverage of whole blood and packed red cells begins only with the fourth pint of blood needed—costs for the first 3 pints of blood in a calendar year must be paid out-of-pocket or the blood must be donated from self or by someone else. All other components of blood are covered beginning with the first pint.
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