Silver Premier Suitcase – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $35 copay
Specialist visit: $95 copay
Urgent care visit: $95 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $4,050 per person $4,050 per person |
| Out-of-pocket max | $8,950 per person $17,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $95 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $95 copay |
| Emergency room | $575 copay after deductible |
| Ambulance | 40% coinsurance after deductible |
| Hospital stay (facility) | $575 copay per Day 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 | $35 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 40% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 copay |
| Brand | $85 copay |
| Non-preferred Brand | $1,600 copay |
| Specialty | $5,000 copay |
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 | $35 copay |
| Psychiatric hospital stay | $575 copay per Day after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://secure.arkansasbluecross.com/members/ViewSbc.aspx?id=32019&year=2024 |
| Drug and medication plan formulary | https://www.arkansasbluecross.com/metallic-formulary-2024 |
| Search doctor list | https://secure.arkansasbluecross.com/providerdirectory/trueblueppo.aspx |
