Blue Saver Silver EPO – EPO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	$100 per person $100 per person
Out-of-pocket max	$1,000 per person $2,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	$5 copay
Specialist visit	$20 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$5 copay
Emergency room	25% coinsurance after deductible
Ambulance	15% coinsurance after deductible
Hospital stay (facility)	10% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	25% coinsurance after deductible
Outpatient procedure (physician)	25% coinsurance after deductible
Physical rehabilitation	15% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	10% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	25% coinsurance after deductible
Non-preferred Brand	25% coinsurance after deductible
Specialty	5% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	25% coinsurance after deductible
Imaging (CT/PET/MRI)	25% coinsurance after deductible
Blood work	25% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$20 copay
Psychiatric hospital stay	10% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.alabamablue.com/sb/2024epo-94.pdf
Drug and medication plan formulary	https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_AL_6T_Source+Rx_1.0.pdf
Search doctor list	https://www.bcbsal.org/web/provider-finder