Blue Cross® Premier PPO Silver – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $30 copay after deductible
Specialist visit: $50 copay after deductible
Urgent care visit: $75 copay
Description
Health Care Plan Details
Network type | PPO |
Deductible | $3,150 per person $3,150 per person |
Out-of-pocket max | $9,100 per person $18,200 per family |
Metal tier | Silver |
Visit Copay
Primary care visit | $30 copay after deductible |
Specialist visit | $50 copay after deductible |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $75 copay |
Emergency room | $250 copay after deductible, 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 | $15 copay after deductible |
Brand | $100 copay after deductible |
Non-preferred Brand | $150 copay 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 | $30 copay after deductible |
Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
Health Plan Benefits | https://www.bcbsm.com/amslibs/content/dam/public/marketplace/2024-individual/sbc/premier-silver-sbc.pdf |
Drug and medication plan formulary | https://www.bcbsm.com/2024-select-ppo-druglist |
Search doctor list | https://www.bcbsm.com/marketplace/ppo/ |