HeartlandBlue Gold $0 PCP Visit 1500 NEtwork Blue – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: 30% coinsurance after deductible
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $1,500 per person $1,500 per person |
| Out-of-pocket max | $7,500 per person $15,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | 30% coinsurance after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | 30% coinsurance after deductible |
| Ambulance | 30% coinsurance after deductible |
| Hospital stay (facility) | 30% coinsurance after deductible |
| Hospital stay (physician) | 30% coinsurance after deductible |
| Outpatient procedure (facility) | 30% coinsurance after deductible |
| Outpatient procedure (physician) | 30% coinsurance after deductible |
| Physical rehabilitation | 30% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | 30% coinsurance after deductible |
| Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | $100 copay |
| Non-preferred Brand | 55% coinsurance after deductible |
| Specialty | 60% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 30% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 30% coinsurance after deductible |
| Blood work | 30% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://sbc.nebraskablue.com/home/retrievesbc/M22929002_2024.pdf |
| Drug and medication plan formulary | https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_NE_6T_HealthInsuranceMarketplace.pdf |
| Search doctor list | https://bcbsne.healthsparq.com/healthsparq/public/#/one/&state=NE&postalCode=&country=US&insurerCode=BCBSNE_I&brandCode=BCBSNE&productCode=1001001001 |
