Blue Preferred Silver PPO℠ 203 – PPO
94% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: 10% coinsurance
Specialist visit: 20% coinsurance
Urgent care visit: 20% coinsurance
Description
This plan has 94% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | PPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $1,200 per person $2,400 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | 10% coinsurance |
| Specialist visit | 20% coinsurance |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 20% coinsurance |
| Emergency room | $500 copay, 20% coinsurance |
| Ambulance | 20% coinsurance |
| Hospital stay (facility) | $250 copay per Stay, 20% coinsurance |
| Hospital stay (physician) | 20% coinsurance |
| Outpatient procedure (facility) | $100 copay, 20% coinsurance |
| Outpatient procedure (physician) | 20% coinsurance |
| Physical rehabilitation | 20% coinsurance |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $250 copay, 20% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | No charge |
| Brand | 20% coinsurance |
| Non-preferred Brand | 35% coinsurance |
| Specialty | 45% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 20% coinsurance |
| Imaging (CT/PET/MRI) | 20% coinsurance |
| Blood work | 20% coinsurance |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 20% coinsurance |
| Psychiatric hospital stay | $250 copay per Stay, 20% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbsmt.com/sbc/ind/sbc-sp6h30ppoimtp-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 |
