Blue Max 90/70 $1500 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$1,500 per person $1,500 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Gold

Visit Copay

Primary care visit	10% coinsurance after deductible
Specialist visit	10% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	10% coinsurance after deductible
Emergency room	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	10% coinsurance after deductible
Brand	10% coinsurance after deductible
Non-preferred Brand	10% coinsurance after deductible
Specialty	10% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	10% coinsurance after deductible
Imaging (CT/PET/MRI)	10% coinsurance after deductible
Blood work	10% coinsurance after deductible

Mental and Psychiatric Health Care

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

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsla.com/web/applications/sbcportal/sbcs/2024/97176LA0340015-01.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