BlueCross S25L $55 PCP Copay + $0 Virtual Care for Medical & Mental Health – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: $55 copay
Specialist visit: $100 copay
Urgent care visit: 50% coinsurance
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $55 copay |
| Specialist visit | $100 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 50% coinsurance |
| Emergency room | $750 copay, 50% coinsurance |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | $2000 copay per Stay, 50% coinsurance |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | $1500 copay, 50% coinsurance |
| Outpatient procedure (physician) | 50% coinsurance |
| Physical rehabilitation | 50% coinsurance |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance |
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 |
| Imaging (CT/PET/MRI) | 50% coinsurance |
| Blood work | 50% coinsurance |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $55 copay |
| Psychiatric hospital stay | 50% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbst.com/sbc/2024/127600/S25L_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 |
