Blue Connect 70/50 $4550 (N) – POS

Description

Health Care Plan Details

Network type	POS
Deductible	$4,550 per person $4,550 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	30% coinsurance after deductible
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	30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	30% 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	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$20 copay
Brand	50% coinsurance after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	30% coinsurance after deductible
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsla.com/web/applications/sbcportal/sbcs/2024/19636LA0240019-01.pdf
Drug and medication plan formulary	http://www.bcbsla.com/pharmacy-3tier-formulary2024
Search doctor list	http://www.bcbsla.com/blueconnect-medical-vision-dental