Blue Advantage Silver PPO℠ 605 – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $100 copay
Specialist visit: $145 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $100 copay |
| Specialist visit | $145 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| Emergency room | $950 copay, 50% coinsurance |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | $400 copay per Stay, 50% coinsurance |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | 50% coinsurance |
| Outpatient procedure (physician) | 50% coinsurance |
| Physical rehabilitation | 50% coinsurance |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $400 copay, 50% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $40 copay |
| Brand | 50% coinsurance |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 50% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 50% coinsurance |
| Imaging (CT/PET/MRI) | 50% coinsurance |
| Blood work | 50% coinsurance |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 50% coinsurance |
| Psychiatric hospital stay | $400 copay per Stay, 50% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbsok.com/sbc/ind/sbc-spsa21bvpiokp-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 |
