BlueCross S04E $0 Virtual Care for Medical & Mental Health – EPO

Network type: EPO
Coverage tier: Silver
Primary care visit: 50% coinsurance after deductible
Specialist visit: 50% coinsurance after deductible
Urgent care visit: 50% coinsurance after deductible

Description

Health Care Plan Details

Network type EPO
Deductible $3,300 per person $3,300 per person
Out-of-pocket max $6,450 per person $12,900 per family
Metal tier Silver

Visit Copay

Primary care visit 50% coinsurance after deductible
Specialist visit 50% coinsurance after deductible
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) 50% coinsurance after deductible
Hospital stay (physician) 50% coinsurance after deductible
Outpatient procedure (facility) 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 50% coinsurance after deductible
Brand 50% coinsurance after deductible
Non-preferred Brand 50% coinsurance after deductible
Specialty 50% coinsurance after deductible

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 50% coinsurance after deductible
Psychiatric hospital stay 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.bcbst.com/sbc/2024/127600/S04E_SBC.pdf
Drug and medication plan formulary https://www.bcbst.com/docs/providers/2024-essential-plus-formulary.pdf
Search doctor list https://www.bcbst.com/network-e