Blue PPO PremierHealth Silver (2 Free In-Network PCP Visits) – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $15 copay
Specialist visit: $75 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
Network type | PPO |
Deductible | $4,100 per person $4,100 per person |
Out-of-pocket max | $9,100 per person $18,200 per family |
Metal tier | Silver |
Visit Copay
Primary care visit | $15 copay |
Specialist visit | $75 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $75 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 | $75 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%20Silver%20&Deductibles=4100&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 |