VantageBlue Direct 750/1500 Modified WPD – PPO
Network type: PPO
Coverage tier: Platinum
Primary care visit: first 1 visit(s) $0 then $20 copay
Specialist visit: $30 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $750 per person $750 per person |
| Out-of-pocket max | $2,000 per person $4,000 per family |
| Metal tier | Platinum |
Visit Copay
| Primary care visit | first 1 visit(s) $0 then $20 copay |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $100 copay |
| Ambulance | $50 copay |
| Hospital stay (facility) | No charge after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Physical rehabilitation | 20% after deductible |
Maternitowny and Pregnancy
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $50 copay |
| Non-preferred Brand | $75 copay |
| Specialty | 20% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge after deductible |
| Imaging (CT/PET/MRI) | No charge after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $20 copay |
| Psychiatric hospital stay | No charge after deductible |
