BluePrime Gold 70 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$500 per person $500 per person
Out-of-pocket max	$8,000 per person $16,000 per family
Metal tier	Gold

Visit Copay

Primary care visit	$25 copay
Specialist visit	$25 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$25 copay
Emergency room	30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	$25 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay after deductible
Brand	$60 copay after deductible
Non-preferred Brand	$150 copay after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$25 copay
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsnd.com/content/dam/bcbsnd/documents/plans/2024/individual-metallic/blueprime/BluePrimeGold70-500_IND_ONX_OFX_20240101_SBC.pdf
Drug and medication plan formulary	http://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_ND_6T_HealthInsuranceMarketplace.pdf
Search doctor list	https://www.bcbsndportals.com/find-a-doctor/#/home