Blue POS Copay 75/55 $1500 Standardized Plan – POS

Network type: POS
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $45 copay

SKU: 19636LA0220019 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type POS
Deductible $1,500 per person $1,500 per person
Out-of-pocket max $8,700 per person $17,400 per family
Metal tier Gold

Visit Copay

Primary care visit $30 copay
Specialist visit $60 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $45 copay
Emergency room 25% coinsurance after deductible
Ambulance 25% coinsurance after deductible
Hospital stay (facility) 25% coinsurance after deductible
Hospital stay (physician) 25% coinsurance after deductible
Outpatient procedure (facility) 25% coinsurance after deductible
Outpatient procedure (physician) 25% coinsurance after deductible
Physical rehabilitation $30 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 25% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $15 copay
Brand $30 copay
Non-preferred Brand $60 copay
Specialty $100 copay

Lab Tests and Diagnostic Procedures

X-rays 25% coinsurance after deductible
Imaging (CT/PET/MRI) 25% coinsurance after deductible
Blood work 25% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services $30 copay
Psychiatric hospital stay 25% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.bcbsla.com/web/applications/sbcportal/sbcs/2024/19636LA0220019-01.pdf
Drug and medication plan formulary http://www.bcbsla.com/pharmacy-4tier-formulary2024
Search doctor list http://www.bcbsla.com/hmopos-medical-vision-dental