Bronze Value – PPO
Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: $65 copay
Specialist visit: $130 copay
Urgent care visit: $130 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $5,900 per person $5,900 per person |
| Out-of-pocket max | $8,800 per person $17,600 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $65 copay |
| Specialist visit | $130 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $130 copay |
| Emergency room | 50% coinsurance after deductible |
| Ambulance | 50% coinsurance after deductible |
| Hospital stay (facility) | 50% coinsurance |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | 50% coinsurance after deductible |
| Outpatient procedure (physician) | 50% coinsurance after deductible |
| Physical rehabilitation | $65 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $30 copay |
| Brand | $160 copay |
| Non-preferred Brand | $1,600 copay |
| Specialty | $5,000 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 50% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 50% coinsurance after deductible |
| Blood work | $60 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $65 copay |
| Psychiatric hospital stay | 50% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://secure.arkansasbluecross.com/members/ViewSbc.aspx?id=34042&year=2024 |
| Drug and medication plan formulary | https://www.arkansasbluecross.com/metallic-formulary-2024 |
| Search doctor list | https://secure.arkansasbluecross.com/providerdirectory/trueblueppo.aspx |
