Blue Plus Minnesota Value Silver Prescription Copay $3750 Plan 404 – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $120 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
Network type | PPO |
Deductible | $3,750 per person $3,750 per person |
Out-of-pocket max | $9,000 per person $18,000 per family |
Metal tier | Silver |
Visit Copay
Primary care visit | $40 copay |
Specialist visit | $120 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $40 copay |
Emergency room | 30% after deductible |
Ambulance | 30% after deductible |
Hospital stay (facility) | 30% after deductible |
Hospital stay (physician) | 30% after deductible |
Outpatient procedure (facility) | 30% after deductible |
Outpatient procedure (physician) | 30% after deductible |
Physical rehabilitation | 30% after deductible |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
Generic | $25 copay |
Brand | $75 copay |
Non-preferred Brand | $225 copay |
Specialty | $675 copay |
Lab Tests and Diagnostic Procedures
X-rays | 30% after deductible |
Imaging (CT/PET/MRI) | 30% after deductible |
Blood work | 30% after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | $40 copay |
Psychiatric hospital stay | 30% after deductible |
Health Plan Provider Information
Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/VA6uhS2gzL8qf7YLsSLJA4sd.pdf |