BlueSolutions for HSA Direct 1700/3400 WAWOPD – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $35 copay after deductible
Specialist visit: $40 copay after deductible
Urgent care visit: $75 copay after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | N/A N/A |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $35 copay after deductible |
| Specialist visit | $40 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay after deductible |
| Emergency room | $300 copay after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | $300 copay after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Physical rehabilitation | $40 copay after deductible |
Maternitowny and Pregnancy
Pharmacy, Drugs, and Medication
| Generic | $10 copay after deductible |
| Brand | $50 copay after deductible |
| Non-preferred Brand | $75 copay after deductible |
| Specialty | 20% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge after deductible |
| Imaging (CT/PET/MRI) | $150 copay after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay after deductible |
| Psychiatric hospital stay | $300 copay after deductible |
