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