Blue Max 70/50 $6700 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$6,700 per person $6,700 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Bronze

Visit Copay

Primary care visit	30% coinsurance after deductible
Specialist visit	30% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	30% coinsurance after deductible
Emergency room	30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	30% coinsurance after deductible
Brand	50% coinsurance after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	30% coinsurance after deductible
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsla.com/web/applications/sbcportal/sbcs/2024/97176LA0340017-01.pdf
Drug and medication plan formulary	http://www.bcbsla.com/pharmacy-2tier-formulary2024
Search doctor list	http://www.bcbsla.com/FindCare/Pages/ppo-medical-vision-dental.aspx