Blue Cross® Local HMO Silver Saver – HMO

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$850 per person $850 per person
Out-of-pocket max	$2,200 per person $4,400 per family
Metal tier	Silver

Visit Copay

Primary care visit	$45 copay
Specialist visit	$90 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$45 copay
Emergency room	$250 copay after deductible, 10% coinsurance after deductible
Ambulance	10% coinsurance after deductible
Hospital stay (facility)	10% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	10% coinsurance after deductible
Outpatient procedure (physician)	10% coinsurance after deductible
Physical rehabilitation	10% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	10% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$4 copay after deductible
Brand	$100 copay after deductible
Non-preferred Brand	$150 copay after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	10% coinsurance after deductible
Imaging (CT/PET/MRI)	10% coinsurance after deductible
Blood work	No charge

Mental and Psychiatric Health Care

Mental Health outpatient services	$45 copay
Psychiatric hospital stay	10% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsm.com/amslibs/content/dam/public/marketplace/2024-individual/sbc/local-silver-saver-87-sbc.pdf
Drug and medication plan formulary	https://www.bcbsm.com/2024-select-hmo-druglist
Search doctor list	https://www.bcbsm.com/marketplace/local-hmo/