Blue Saver 60/40 $6100 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$6,100 per person $6,100 per person
Out-of-pocket max	$8,000 per person $16,000 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	40% coinsurance after deductible
Specialist visit	40% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	40% coinsurance after deductible
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% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	40% coinsurance after deductible
Brand	60% coinsurance after deductible
Non-preferred Brand	60% coinsurance after deductible
Specialty	60% coinsurance 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% coinsurance after deductible
Psychiatric hospital stay	40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsla.com/web/applications/sbcportal/sbcs/2024/97176LA0350004-01.pdf
Drug and medication plan formulary	http://www.bcbsla.com/pharmacy-2tier-formulary2024
Search doctor list	http://www.bcbsla.com/FindCare/Pages/ppo-medical-vision-dental.aspx