Blue Cross® Preferred HMO Gold – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $50 copay after deductible
Urgent care visit: $40 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,700 per person $1,700 per person |
| Out-of-pocket max | $9,400 per person $18,800 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $50 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay |
| Emergency room | $250 copay after deductible, 20% coinsurance after deductible |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | 20% coinsurance after deductible |
| Hospital stay (physician) | 20% coinsurance after deductible |
| Outpatient procedure (facility) | 20% coinsurance after deductible |
| Outpatient procedure (physician) | 20% coinsurance after deductible |
| Physical rehabilitation | 20% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% 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 | 20% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 20% coinsurance after deductible |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbsm.com/amslibs/content/dam/public/marketplace/2024-individual/sbc/preferred-gold-sbc.pdf |
| Drug and medication plan formulary | https://www.bcbsm.com/2024-select-hmo-druglist |
| Search doctor list | https://www.bcbsm.com/marketplace/preferred-hmo/ |
