IN-NETWORK
BENEFITS |
Silver PPOS531
|
Bronze PPO (HSA)B535
|
Platinum HMOP506
|
Network |
Participating Provider Organization (PPO) |
Participating Provider Organization (PPO) |
Blue Precision HMO |
Preventive Care*Preventive Care is defined by the Affordable Care Act (ACA) Visit HealthCare.gov to access a list of covered preventive services by gender and age |
100% Covered |
100% Covered |
100% Covered |
Office Visit Copay |
$50 PCP$75 Non-PCP$50 Virtual Visits
$80 Urgent Care
|
No charge after deductible is met |
$15 PCP$45 Non-PCP$45 Urgent Care |
Emergency Room Copay |
$500 per visit, plus
|
$250 copay,plus deductible |
$300 per visit |
Prescription Drugs |
$5 Tier 1$60 Tier 2$110 Tier 3$250 Tier 4 |
No Charge after deductible |
$5 Tier 1$60 Tier 2$110 Tier 3$250 Tier 4 |
Deductible |
$5,100 Single$15,300 Family
|
$7,300 Single$14,600 Family |
$0 Single$0 Family
|
Coinsurance |
You pay 30% (after deductible)
|
You pay 0% (after deductible)
|
You pay 0% (after deductible)
|
Out-of-Pocket Maximum |
$9,200 Single$18,400 Family
|
$7,300 Single
|
$1,750 Single$5,250 Family
|






















