BlueSolutions for HSA Direct 4100/8200 WPD – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: 20% after deductible
Specialist visit: 20% after deductible
Urgent care visit: 20% after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $4,100 per person $4,100 per person |
| Out-of-pocket max | $6,200 per person $12,400 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | 20% after deductible |
| Specialist visit | 20% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 20% after deductible |
| Emergency room | 20% after deductible |
| Ambulance | $50 copay after deductible |
| Hospital stay (facility) | 20% after deductible |
| Outpatient procedure (facility) | 20% after deductible |
| Physical rehabilitation | 20% 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 | 20% after deductible |
| Imaging (CT/PET/MRI) | 20% after deductible |
| Blood work | 20% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 20% after deductible |
| Psychiatric hospital stay | 20% after deductible |
