Blue Preferred Bronze PPO℠ 202 – PPO
Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: 30% coinsurance after deductible
Specialist visit: 30% coinsurance after deductible
Urgent care visit: 30% coinsurance after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $4,000 per person $4,000 per person |
| Out-of-pocket max | $7,500 per person $15,000 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | 30% coinsurance after deductible |
| Specialist visit | 30% coinsurance after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 30% coinsurance after deductible |
| Emergency room | $1000 copay after deductible, 30% coinsurance after deductible |
| Ambulance | 30% coinsurance after deductible |
| Hospital stay (facility) | $850 copay per Stay after deductible, 30% coinsurance after deductible |
| Hospital stay (physician) | 30% coinsurance after deductible |
| Outpatient procedure (facility) | $600 copay after deductible, 30% coinsurance after deductible |
| Outpatient procedure (physician) | $200 copay after deductible, 30% coinsurance after deductible |
| Physical rehabilitation | 30% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $850 copay, 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | 20% coinsurance after deductible |
| Brand | 30% coinsurance after deductible |
| Non-preferred Brand | 35% coinsurance after deductible |
| Specialty | 45% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 30% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 30% coinsurance after deductible |
| Blood work | 30% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 30% coinsurance after deductible |
| Psychiatric hospital stay | $850 copay per Stay after deductible, 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbsmt.com/sbc/ind/sbc-bpsh31ppoimtp-mt-2024.pdf |
| Drug and medication plan formulary | https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_MT_6T_HIM.pdf |
| Search doctor list | https://my.providerfinderonline.com/?ci=mt-bluepreferredppo-retail&corp_code=MT |
