DakotaBlue Altru Silver 60 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$3,000 per person $3,000 per person
Out-of-pocket max	$9,400 per person $18,800 per family
Metal tier	Silver

Visit Copay

Primary care visit	$20 copay
Specialist visit	$80 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$20 copay
Emergency room	40% coinsurance after deductible
Ambulance	40% coinsurance after deductible
Hospital stay (facility)	40% coinsurance after deductible
Hospital stay (physician)	40% coinsurance after deductible
Outpatient procedure (facility)	40% coinsurance after deductible
Outpatient procedure (physician)	40% coinsurance after deductible
Physical rehabilitation	$20 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$20 copay
Brand	$150 copay
Non-preferred Brand	$200 copay
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	40% coinsurance after deductible
Imaging (CT/PET/MRI)	40% coinsurance after deductible
Blood work	40% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$20 copay
Psychiatric hospital stay	40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsnd.com/content/dam/bcbsnd/documents/plans/2024/individual-metallic/dakotablue-altru/DakotaBlueSilverAltru60-3000_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