Blue Advantage Silver PPO℠ 204 – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: 40% coinsurance after deductible
Specialist visit: 50% coinsurance after deductible
Urgent care visit: 50% coinsurance after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $1,200 per person $1,200 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | 40% 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 | $950 copay after deductible, 50% coinsurance after deductible |
| Ambulance | 50% coinsurance after deductible |
| Hospital stay (facility) | $400 copay per Stay after deductible, 50% coinsurance after deductible |
| Hospital stay (physician) | 50% coinsurance after deductible |
| Outpatient procedure (facility) | $300 copay after deductible, 40% coinsurance after deductible |
| Outpatient procedure (physician) | $200 copay after deductible, 50% coinsurance after deductible |
| Physical rehabilitation | 50% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $400 copay after deductible, 50% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | 20% coinsurance after deductible |
| Brand | 30% coinsurance after deductible |
| Non-preferred Brand | 35% coinsurance after deductible |
| Specialty | 45% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 40% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 40% coinsurance after deductible |
| Blood work | 40% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 50% coinsurance after deductible |
| Psychiatric hospital stay | $400 copay per Stay after deductible, 50% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbsok.com/sbc/ind/sbc-spsh31bvpiokp-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 |
