Blue Plus Southeast MN HSA Silver $3200 Plan 471 – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: 30% after deductible
Specialist visit: 30% after deductible
Urgent care visit: 30% after deductible
Description
Health Care Plan Details
Network type | PPO |
Deductible | $3,200 per person $3,200 per person |
Out-of-pocket max | $7,600 per person $15,200 per family |
Metal tier | Silver |
Visit Copay
Primary care visit | 30% after deductible |
Specialist visit | 30% after deductible |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | 30% after deductible |
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 | 30% after deductible |
Brand | 30% after deductible |
Non-preferred Brand | 50% after deductible |
Specialty | 30% after deductible |
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 | 30% after deductible |
Psychiatric hospital stay | 30% after deductible |
Health Plan Provider Information
Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/BpiaNSnTor3ho5Jqnu7ocGjT.pdf |