Blue Value Silver – PPO

Network type: PPO
Coverage tier: Silver
Primary care visit: $50 copay
Specialist visit: $80 copay
Urgent care visit: $50 copay

SKU: 46944AL0410001 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type PPO
Deductible $4,000 per person $4,000 per person
Out-of-pocket max $9,250 per person $18,500 per family
Metal tier Silver

Visit Copay

Primary care visit $50 copay
Specialist visit $80 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $50 copay
Emergency room $650 copay
Ambulance 20% coinsurance after deductible
Hospital stay (facility) 20% coinsurance
Hospital stay (physician) No charge after deductible
Outpatient procedure (facility) $600 copay
Outpatient procedure (physician) No charge after deductible
Physical rehabilitation 20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 20% coinsurance

Pharmacy, Drugs, and Medication

Generic $20 copay
Brand $85 copay
Non-preferred Brand 50% coinsurance
Specialty $250 copay

Lab Tests and Diagnostic Procedures

X-rays No charge
Imaging (CT/PET/MRI) $600 copay
Blood work No charge

Mental and Psychiatric Health Care

Mental Health outpatient services $80 copay
Psychiatric hospital stay No charge

Health Plan Provider Information

Health Plan Benefits https://www.alabamablue.com/sb/2024vsi.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