HeartlandBlue Gold Standard 1500 Blueprint Health – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $45 copay
Description
Health Care Plan Details
Network type | EPO |
Deductible | $1,500 per person $1,500 per person |
Out-of-pocket max | $8,700 per person $17,400 per family |
Metal tier | Gold |
Visit Copay
Primary care visit | $30 copay |
Specialist visit | $60 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $45 copay |
Emergency room | 25% coinsurance after deductible |
Ambulance | 25% coinsurance after deductible |
Hospital stay (facility) | 25% coinsurance after deductible |
Hospital stay (physician) | 25% coinsurance after deductible |
Outpatient procedure (facility) | 25% coinsurance after deductible |
Outpatient procedure (physician) | 25% coinsurance after deductible |
Physical rehabilitation | $30 copay |
Maternitowny and Pregnancy
Well baby care | 25% coinsurance after deductible |
Labor, delivery, hospital stay | 25% coinsurance after deductible |
Pharmacy, Drugs, and Medication
Generic | $15 copay |
Brand | $30 copay |
Non-preferred Brand | $60 copay |
Specialty | $250 copay |
Lab Tests and Diagnostic Procedures
X-rays | 25% coinsurance after deductible |
Imaging (CT/PET/MRI) | 25% coinsurance after deductible |
Blood work | 25% coinsurance after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | $30 copay |
Psychiatric hospital stay | 25% coinsurance after deductible |
Health Plan Provider Information
Health Plan Benefits | https://sbc.nebraskablue.com/home/retrievesbc/M23233002_2024.pdf |
Drug and medication plan formulary | https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_NE_4T_HealthInsuranceMarketplace.pdf |
Search doctor list | https://bcbsne.healthsparq.com/healthsparq/public/#/one/&state=NE&postalCode=&country=US&insurerCode=BCBSNE_I&brandCode=BCBSNE&productCode=1000001000 |