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