Blue Choice Select PPO 1124 | In-Network | Out-of-Network |
Physician Office Visits |
PCP: $30 Copay
Specialist: $50 Copay
|
Deductive then Coinsurance |
Calendar Year Deductible | $3,000 Single / $9,000 Family | $6,000 Single / $18,000 Family |
Coinsurance (Plan Pays / You Pay) | 80% / 20% | 50% / 50% |
Out-of-Pocket Maximum |
$6,000 Single / $17,100 Family | $18,000 / $51,300 Family |
Annual Routine Physical |
No cost sharing for preventive services
|
Deductible then Coinsurance |
Emergency Room Visits |
$200 Copay
|
$200 Copay
|
Inpatient Hospital Services | Deductible then Coinsurance |
$300 Copay then
Deductible then Coinsurance
|