Blue Connect copay 95/50 $200 CSR 0009-06 (L) – POS

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	POS
Deductible	$200 per person $200 per person
Out-of-pocket max	$1,200 per person $2,400 per family
Metal tier	Silver

Visit Copay

Primary care visit	$5 copay
Specialist visit	$25 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$25 copay
Emergency room	5% coinsurance after deductible
Ambulance	5% coinsurance after deductible
Hospital stay (facility)	5% coinsurance after deductible
Hospital stay (physician)	5% coinsurance after deductible
Outpatient procedure (facility)	5% coinsurance after deductible
Outpatient procedure (physician)	5% coinsurance after deductible
Physical rehabilitation	$5 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	5% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	5% coinsurance after deductible
Brand	25% coinsurance after deductible
Non-preferred Brand	25% coinsurance after deductible
Specialty	25% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	5% coinsurance after deductible
Imaging (CT/PET/MRI)	5% coinsurance after deductible
Blood work	5% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$5 copay
Psychiatric hospital stay	5% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsla.com/web/applications/sbcportal/sbcs/2024/19636LA0240009-06.pdf
Drug and medication plan formulary	http://www.bcbsla.com/pharmacy-2tier-formulary2024
Search doctor list	http://www.bcbsla.com/blueconnect-medical-vision-dental