Blue Cross® Premier PPO Gold – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$1,200 per person $1,200 per person
Out-of-pocket max	$8,500 per person $17,000 per family
Metal tier	Gold

Visit Copay

Primary care visit	$30 copay after deductible
Specialist visit	$50 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$75 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	$15 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	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$30 copay after deductible
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/premier-gold-sbc.pdf
Drug and medication plan formulary	https://www.bcbsm.com/2024-select-ppo-druglist
Search doctor list	https://www.bcbsm.com/marketplace/ppo/