Blue Connect 80/60 $3400 (N) – POS

Description

Health Care Plan Details

Network type	POS
Deductible	$3,400 per person $3,400 per person
Out-of-pocket max	$7,900 per person $15,800 per family
Metal tier	Silver

Visit Copay

Primary care visit	20% coinsurance after deductible
Specialist visit	20% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	20% coinsurance after deductible
Emergency room	20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	20% coinsurance after deductible
Brand	40% coinsurance after deductible
Non-preferred Brand	40% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	20% coinsurance after deductible
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsla.com/web/applications/sbcportal/sbcs/2024/19636LA0240007-01.pdf
Drug and medication plan formulary	http://www.bcbsla.com/pharmacy-2tier-formulary2024
Search doctor list	http://www.bcbsla.com/blueconnect-medical-vision-dental