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