Blue Preferred Silver PPO℠ 701 – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
Network type | PPO |
Deductible | $5,900 per person $5,900 per person |
Out-of-pocket max | $9,100 per person $18,200 per family |
Metal tier | Silver |
Visit Copay
Primary care visit | $40 copay |
Specialist visit | $80 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $60 copay |
Emergency room | 40% coinsurance after deductible |
Ambulance | 40% coinsurance after deductible |
Hospital stay (facility) | 40% coinsurance after deductible |
Hospital stay (physician) | 40% coinsurance after deductible |
Outpatient procedure (facility) | 40% coinsurance after deductible |
Outpatient procedure (physician) | 40% coinsurance after deductible |
Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
Well baby care | No charge |
Labor, delivery, hospital stay | 40% coinsurance after deductible |
Pharmacy, Drugs, and Medication
Generic | $20 copay |
Brand | $40 copay |
Non-preferred Brand | $80 copay after deductible |
Specialty | $350 copay after deductible |
Lab Tests and Diagnostic Procedures
X-rays | 40% coinsurance after deductible |
Imaging (CT/PET/MRI) | 40% coinsurance after deductible |
Blood work | 40% coinsurance after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | $40 copay |
Psychiatric hospital stay | 40% coinsurance after deductible |
Health Plan Provider Information
Health Plan Benefits | https://www.bcbsok.com/sbc/ind/sbc-spsa63eppiokp-ok-2024.pdf |
Drug and medication plan formulary | https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_OK_4T_HIM.pdf |
Search doctor list | https://my.providerfinderonline.com/?ci=ok-bluepreferredppo-retail&corp_code=OK |