HeartlandBlue Gold $0 Deductible NEtwork Blue – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: 35% coinsurance
Specialist visit: 35% coinsurance
Urgent care visit: 35% coinsurance
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | Success
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| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | 35% coinsurance |
| Specialist visit | 35% coinsurance |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 35% coinsurance |
| Emergency room | 35% coinsurance |
| Ambulance | 35% coinsurance |
| Hospital stay (facility) | 35% coinsurance |
| Hospital stay (physician) | 35% coinsurance |
| Outpatient procedure (facility) | 35% coinsurance |
| Outpatient procedure (physician) | 35% coinsurance |
| Physical rehabilitation | 35% coinsurance |
Maternitowny and Pregnancy
| Well baby care | 35% coinsurance |
| Labor, delivery, hospital stay | 35% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | $100 copay |
| Non-preferred Brand | 55% coinsurance |
| Specialty | 60% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 35% coinsurance |
| Imaging (CT/PET/MRI) | 35% coinsurance |
| Blood work | 35% coinsurance |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 35% coinsurance |
| Psychiatric hospital stay | 35% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://sbc.nebraskablue.com/home/retrievesbc/M22905002_2024.pdf |
| Drug and medication plan formulary | https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_NE_6T_HealthInsuranceMarketplace.pdf |
| Search doctor list | https://bcbsne.healthsparq.com/healthsparq/public/#/one/&state=NE&postalCode=&country=US&insurerCode=BCBSNE_I&brandCode=BCBSNE&productCode=1001001001 |
