Blue Preferred Gold PPO℠ 204 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$750 per person $750 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Gold

Visit Copay

Primary care visit	$10 copay
Specialist visit	30% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$15 copay
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)	30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	$850 copay after deductible, 30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	$50 copay
Non-preferred Brand	$100 copay
Specialty	$250 copay

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-gpsh30ppoimtp-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