Blue Cross Select Gold – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $35 copay
Specialist visit: $50 copay
Urgent care visit: $35 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $850 per person $850 per person |
| Out-of-pocket max | $6,000 per person $12,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $35 copay |
| Emergency room | $300 copay |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | $300 copay per Day |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $300 copay |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | 20% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $300 copay |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $55 copay |
| Non-preferred Brand | 40% coinsurance |
| Specialty | $175 copay |
Lab Tests and Diagnostic Procedures
| X-rays | No charge |
| Imaging (CT/PET/MRI) | $300 copay |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | No charge |
Health Plan Provider Information
| Health Plan Benefits | https://www.alabamablue.com/sb/2024csg.pdf |
| Drug and medication plan formulary | https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_AL_6T_Source+Rx_1.0.pdf |
| Search doctor list | https://www.bcbsal.org/web/provider-finder |
