Blue Plus Minnesota Value Bronze $5800 Plan 403 – PPO
Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: first 3 visit(s) $35 then 35% after deductible copay, first 3 visit(s) $35 then 35% after deductible
Specialist visit: first 3 visit(s) $35 then 35% after deductible copay, first 3 visit(s) $35 then 35% after deductible
Urgent care visit: first 3 visit(s) $35 then 35% after deductible copay, first 3 visit(s) $35 then 35% after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $5,800 per person $5,800 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | first 3 visit(s) $35 then 35% after deductible copay, first 3 visit(s) $35 then 35% after deductible |
| Specialist visit | first 3 visit(s) $35 then 35% after deductible copay, first 3 visit(s) $35 then 35% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | first 3 visit(s) $35 then 35% after deductible copay, first 3 visit(s) $35 then 35% after deductible |
| Emergency room | 35% after deductible |
| Ambulance | 35% after deductible |
| Hospital stay (facility) | 35% after deductible |
| Hospital stay (physician) | 35% after deductible |
| Outpatient procedure (facility) | 35% after deductible |
| Outpatient procedure (physician) | 35% after deductible |
| Physical rehabilitation | 35% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 35% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | 35% after deductible |
| Non-preferred Brand | 60% after deductible |
| Specialty | 35% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 35% after deductible |
| Imaging (CT/PET/MRI) | 35% after deductible |
| Blood work | 35% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 3 visit(s) $35 then 35% after deductible copay, first 3 visit(s) $35 then 35% after deductible |
| Psychiatric hospital stay | 35% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/a4kFbBFHhgn91aYDtNbdYdeF.pdf |
