Blue Max Copay 50/50 $3300 – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $65 copay
Urgent care visit: $65 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $3,300 per person $3,300 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $65 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $65 copay |
| Emergency room | 50% coinsurance after deductible |
| Ambulance | 50% coinsurance after deductible |
| Hospital stay (facility) | 50% coinsurance after deductible |
| Hospital stay (physician) | 50% coinsurance after deductible |
| Outpatient procedure (facility) | 50% coinsurance after deductible |
| Outpatient procedure (physician) | 50% coinsurance after deductible |
| Physical rehabilitation | 50% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay after deductible |
| Brand | 20% coinsurance after deductible |
| Non-preferred Brand | 30% coinsurance after deductible |
| Specialty | 20% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 50% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 50% coinsurance after deductible |
| Blood work | 50% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | 50% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbsla.com/web/applications/sbcportal/sbcs/2024/97176LA0340010-01.pdf |
| Drug and medication plan formulary | http://www.bcbsla.com/pharmacy-3tier-formulary2024 |
| Search doctor list | http://www.bcbsla.com/FindCare/Pages/ppo-medical-vision-dental.aspx |
