BasicBlue Direct 2500/5000 WAPD – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $25 copay
Specialist visit: $30 copay
Urgent care visit: $75 copay after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $2,500 per person $2,500 per person |
| Out-of-pocket max | $5,900 per person $11,800 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $25 copay |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay after deductible |
| Emergency room | 10% after deductible |
| Ambulance | $50 copay |
| Hospital stay (facility) | 10% after deductible |
| Outpatient procedure (facility) | 10% after deductible |
| Physical rehabilitation | 10% after deductible |
Maternitowny and Pregnancy
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $50 copay after deductible |
| Non-preferred Brand | $75 copay after deductible |
| Specialty | 20% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 10% after deductible |
| Imaging (CT/PET/MRI) | 10% after deductible |
| Blood work | 10% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $25 copay |
| Psychiatric hospital stay | 10% after deductible |
