Blue PPO PremierHealth Gold (2 Free In-Network PCP Visits) – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $5 copay
Specialist visit: $25 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $1,250 per person $1,250 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $5 copay |
| Specialist visit | $25 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| 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 | $3 copay |
| 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 | $25 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://common.secure.azblue.com/SBC/GetSBC?ProductName=PPO%20PremierHealth%20Gold%20&Deductibles=1250&EffectiveDate=2024/01/01&ContractType=2.pdf |
| Drug and medication plan formulary | https://www.azblue.com/blueexchangeselect3tierformulary |
| Search doctor list | https://www.azblue.com/ppo |
