BlueCross S24L $35 PCP Copay + $0 Virtual Care for Medical & Mental Health – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$5,450 per person $5,450 per person
Out-of-pocket max	$8,900 per person $17,800 per family
Metal tier	Silver

Visit Copay

Primary care visit	$35 copay
Specialist visit	$75 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	50% coinsurance after deductible
Emergency room	$750 copay after deductible, 50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	$2000 copay per Stay after deductible, 50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	$1500 copay after deductible, 50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$60 copay
Brand	$100 copay
Non-preferred Brand	$250 copay
Specialty	50% coinsurance

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	50% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$35 copay
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbst.com/sbc/2024/127600/S24L_SBC.pdf
Drug and medication plan formulary	https://www.bcbst.com/docs/providers/2024-essential-formulary.pdf
Search doctor list	https://www.bcbst.com/network-l