my Blue Access PPO Bronze 3800 + Adult Dental and Vision – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$3,800 per person $3,800 per person
Out-of-pocket max	$9,200 per person $18,400 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$75 copay
Specialist visit	$75 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$100 copay
Emergency room	50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	$375 copay after deductible
Outpatient procedure (physician)	$375 copay after deductible
Physical rehabilitation	$17 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	50% coinsurance after deductible
Brand	50% coinsurance after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	$150 copay
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	$65 copay

Mental and Psychiatric Health Care

Mental Health outpatient services	$75 copay
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://shop.highmark.com/content/dam/highmark/en/healthco/shopx/plan-documents/2024/sbcs/hmde/individual/I_76168DE0700001-01_20240101_SBC.pdf
Drug and medication plan formulary	https://client.formularynavigator.com/Search.aspx?siteCode=6571849149
Search doctor list	https://highmark.sapphirecareselect.com/?ci=hmbcbsde&network_id=402