BlueCross B07L HSA + $0 Virtual Care for Medical & Mental Health – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$5,950 per person $5,950 per person
Out-of-pocket max	$7,100 per person $14,200 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	50% coinsurance after deductible
Specialist visit	50% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	50% coinsurance after deductible
Emergency room	$750 copay after deductible, 50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	50% coinsurance after deductible
Brand	50% coinsurance after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	50% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	50% coinsurance after deductible
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbst.com/sbc/2024/127600/B07L_SBC.pdf
Drug and medication plan formulary	https://www.bcbst.com/docs/providers/2024-essential-formulary.pdf
Search doctor list	https://www.bcbst.com/network-l