Blue Advantage Gold PPO℠ 604 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$1,150 per person $1,150 per person
Out-of-pocket max	$9,450 per person $18,900 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	30% coinsurance after deductible
Emergency room	$950 copay after deductible, 30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	$400 copay per Stay after deductible, 30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	$400 copay, 30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	No charge
Brand	30% coinsurance after deductible
Non-preferred Brand	35% coinsurance after deductible
Specialty	45% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	30% coinsurance after deductible
Psychiatric hospital stay	$400 copay per Stay after deductible, 30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsok.com/sbc/ind/sbc-gpsa30bvpiokp-ok-2024.pdf
Drug and medication plan formulary	https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_OK_6T_HIM.pdf
Search doctor list	https://my.providerfinderonline.com/?ci=ok-blueadvantageppo-retail&corp_code=OK