Blue Plus Minnesota Value HSA Gold $3200 Plan 407 – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: 5% after deductible
Specialist visit: 5% after deductible
Urgent care visit: 5% after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $3,200 per person $3,200 per person |
| Out-of-pocket max | $4,800 per person $14,400 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | 5% after deductible |
| Specialist visit | 5% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 5% after deductible |
| Emergency room | 5% after deductible |
| Ambulance | 5% after deductible |
| Hospital stay (facility) | 5% after deductible |
| Hospital stay (physician) | 5% after deductible |
| Outpatient procedure (facility) | 5% after deductible |
| Outpatient procedure (physician) | 5% after deductible |
| Physical rehabilitation | 5% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 5% after deductible |
Pharmacy, Drugs, and Medication
| Generic | 5% after deductible |
| Brand | 5% after deductible |
| Non-preferred Brand | 20% after deductible |
| Specialty | 5% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 5% after deductible |
| Imaging (CT/PET/MRI) | 5% after deductible |
| Blood work | 5% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 5% after deductible |
| Psychiatric hospital stay | 5% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/PrQMKJMgUQJdWrF9wbL2xTs3.pdf |
