BlueDirect Gold 90 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$2,600 per person $2,600 per person
Out-of-pocket max	$4,300 per person $8,600 per family
Metal tier	Gold

Visit Copay

Primary care visit	10% coinsurance after deductible
Specialist visit	10% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	10% coinsurance after deductible
Emergency room	10% coinsurance after deductible
Ambulance	10% coinsurance after deductible
Hospital stay (facility)	10% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	10% coinsurance after deductible
Outpatient procedure (physician)	10% coinsurance after deductible
Physical rehabilitation	10% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	10% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	10% coinsurance after deductible
Brand	10% coinsurance after deductible
Non-preferred Brand	10% coinsurance after deductible
Specialty	20% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	10% coinsurance after deductible
Imaging (CT/PET/MRI)	10% coinsurance after deductible
Blood work	10% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	10% coinsurance after deductible
Psychiatric hospital stay	10% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsnd.com/content/dam/bcbsnd/documents/plans/2024/individual-metallic/bluedirect/BlueDirectGold90-2600_IND_ONX_OFX_20240101_SBC.pdf
Drug and medication plan formulary	http://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_ND_6T_HealthInsuranceMarketplace.pdf
Search doctor list	https://www.bcbsndportals.com/find-a-doctor/#/home