myBlue Silver 2204 ($0 Virtual Visits / Rewards $$$)

Health Insurance Plan Details (2024 Plan)

SBC doc

doctor lookup

drug list

HMO

Silver

Deductible (per individual)	$4,750 /yr
Deductible (per family)	$9,500 /yr
Max Out-of-Pocket (per individual)	$7,800 /yr
Max Out-of-Pocket (per family)	$15,600 /yr
Drug Deductible (per individual)	Included in Medical
Drug Deductible (per family)	Included in Medical
Drug Max Out-of-Pocket (per individual)	Included in Medical
Drug Max Out-of-Pocket (per family)	Included in Medical
Plan Type	HMO
Includes Child Dental?	No
Includes Adult Dental?	No

Medical Services
Preventive Care	No Charge
Primary Care Visit	No Charge
Specialist Visit	$20 Copay
Emergency Room	$650 Copay after deductible
Inpatient Facility	40% Coinsurance after deductible
Inpatient Physician	No Charge

Drug Costs
Generic Drugs	$25 Copay
Preferred Brand Drugs	$55 Copay after deductible
Non-preferred Brand Drugs	50% Coinsurance after deductible
Specialty Drugs	50% Coinsurance after deductible

Summary of Benefits and Coverage	SBC doc
Provider Directory	Doctor lookup
Drug Formulary List	drug list

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible

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