Blue Max copay 95/50 $100 CSR 0010-06 – PPO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	PPO
Deductible	$100 per person $100 per person
Out-of-pocket max	$1,800 per person $3,600 per family
Metal tier	Silver

Visit Copay

Primary care visit	$5 copay
Specialist visit	$20 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$20 copay
Emergency room	5% coinsurance after deductible
Ambulance	5% coinsurance after deductible
Hospital stay (facility)	5% coinsurance after deductible
Hospital stay (physician)	5% coinsurance after deductible
Outpatient procedure (facility)	5% coinsurance after deductible
Outpatient procedure (physician)	5% coinsurance after deductible
Physical rehabilitation	5% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	5% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$7 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	5% coinsurance after deductible
Imaging (CT/PET/MRI)	5% coinsurance after deductible
Blood work	5% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$5 copay
Psychiatric hospital stay	5% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsla.com/web/applications/sbcportal/sbcs/2024/97176LA0340010-06.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