Blue PPO Portfolio HSA Gold – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$2,500 per person $2,500 per person
Out-of-pocket max	$4,500 per person $9,000 per family
Metal tier	Gold

Visit Copay

Primary care visit	20% coinsurance after deductible
Specialist visit	20% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	20% coinsurance after deductible
Emergency room	20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	20% coinsurance after deductible
Brand	20% coinsurance after deductible
Non-preferred Brand	20% coinsurance after deductible
Specialty	20% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	20% coinsurance after deductible
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://common.secure.azblue.com/SBC/GetSBC?ProductName=PPO%20Portfolio%20HSA%20Gold%20&Deductibles=2500&EffectiveDate=2024/01/01&ContractType=2.pdf
Drug and medication plan formulary	https://www.azblue.com/blueexchangeselectformulary
Search doctor list	https://www.azblue.com/ppo