Blue Plus Metro MN HSA Bronze $8050 Plan 458 – PPO

Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: No charge after deductible
Specialist visit: No charge after deductible
Urgent care visit: No charge after deductible

Description

Health Care Plan Details

Network type PPO
Deductible $8,050 per person $8,050 per person
Out-of-pocket max $8,050 per person $16,100 per family
Metal tier Expanded Bronze

Visit Copay

Primary care visit No charge after deductible
Specialist visit No charge after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care No charge after deductible
Emergency room No charge after deductible
Ambulance No charge after deductible
Hospital stay (facility) No charge after deductible
Hospital stay (physician) No charge after deductible
Outpatient procedure (facility) No charge after deductible
Outpatient procedure (physician) No charge after deductible
Physical rehabilitation No charge after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay No charge after deductible

Pharmacy, Drugs, and Medication

Generic No charge after deductible
Brand No charge after deductible
Non-preferred Brand No charge after deductible
Specialty No charge after deductible

Lab Tests and Diagnostic Procedures

X-rays No charge after deductible
Imaging (CT/PET/MRI) No charge after deductible
Blood work No charge after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services No charge after deductible
Psychiatric hospital stay No charge after deductible

Health Plan Provider Information

Health Plan Benefits https://d2ed110nmrd591.cloudfront.net/blobs/6mX3mY2TjBiVVrH8Zvwyjk4d.pdf