Blue Preferred Silver PPOв„  201

Health Insurance Plan Details (2024 Plan)

by Blue Cross Blue Shield of Oklahoma

Monthly Premium

PPO
$ubsidy
Silver
Deductible
$1,750 /yr
Max Out-of-Pocket
$9,450 /yr

Details

Deductible (per individual) $1,750 /yr
Deductible (per family) $3,500 /yr
Max Out-of-Pocket (per individual) $9,450 /yr
Max Out-of-Pocket (per family) $18,900 /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 PPO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit No Charge
Specialist Visit 50% Coinsurance after deductible
Emergency Room $950 Copay with deductible and 50% Coinsurance after deductible
Inpatient Facility $400 Copay per Stay with deductible and 50% Coinsurance after deductible
Inpatient Physician 50% Coinsurance after deductible
Drug Costs
Generic Drugs $5 Copay
Preferred Brand Drugs 30% Coinsurance after deductible
Non-preferred Brand Drugs 35% Coinsurance after deductible
Specialty Drugs 45% Coinsurance after deductible

Plan Documents

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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