Blue Plus Southeast MN Gold Prescription Copay $1100 Plan 472 – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: 20% after deductible
Specialist visit: 20% after deductible
Urgent care visit: 20% after deductible
Description
Health Care Plan Details
Network type | PPO |
Deductible | $1,100 per person $1,100 per person |
Out-of-pocket max | $7,500 per person $15,000 per family |
Metal tier | Gold |
Visit Copay
Primary care visit | 20% after deductible |
Specialist visit | 20% after deductible |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | 20% after deductible |
Emergency room | 20% after deductible |
Ambulance | 20% after deductible |
Hospital stay (facility) | 20% after deductible |
Hospital stay (physician) | 20% after deductible |
Outpatient procedure (facility) | 20% after deductible |
Outpatient procedure (physician) | 20% after deductible |
Physical rehabilitation | 20% after deductible |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | 20% after deductible |
Pharmacy, Drugs, and Medication
Generic | $20 copay |
Brand | $60 copay |
Non-preferred Brand | $180 copay |
Specialty | $540 copay |
Lab Tests and Diagnostic Procedures
X-rays | 20% after deductible |
Imaging (CT/PET/MRI) | 20% after deductible |
Blood work | 20% after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | 20% after deductible |
Psychiatric hospital stay | 20% after deductible |
Health Plan Provider Information
Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/o5ohpCM1FMSwRoJY9BJK8BPB.pdf |