Blue Standardized Silver – PPO

Network type: PPO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $60 copay

SKU: 46944AL0730001 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

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.alabamablue.com/sb/2024sts.pdf
Drug and medication plan formulary https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_AL_4T_Standardized_Source+Rx_1.0.pdf
Search doctor list https://www.bcbsal.org/web/provider-finder