Blue Preferred Gold PPO℠ 204 – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $10 copay
Specialist visit: 30% coinsurance after deductible
Urgent care visit: $15 copay
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 |
