Blue Max Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan - PPO

Plan summary
Get our guide to the Essential Health Benefits covered by this plan and all other Marketplace plans.
Your premium is the amount you pay for health insurance each month.
Deductible
$1,500 per person
$1,500 per person
Your deductible is the amount you pay for healthcare services before your insurance starts helping you cover the cost.
Depending on the plan, some basic services (like doctor visits and prescriptions) may be covered before your deductible is met.
Out-of-pocket max
$7,800 per person
$15,600 per family
This is the most you will have to pay for healthcare services during your coverage period (typically 12 months).
After you spend this amount on deductibles, copayments, and coinsurance, your health insurance plan will pay the rest.
Note: monthly premiums don’t count towards your out-of-pocket max.
Network type
PPO
The type of network you choose (HMO, PPO, POS, or EPO) will determine which providers (doctors, pharmacies, hospitals, and specialist) you can see.
HMO plans usually limit coverage to providers who are within the plan’s network, and require a doctor’s referral to see specialists.
PPO plans usually cover some of the cost of out-of-network providers (but not as much as for in-network providers), and don’t require a doctor’s referral to see specialists.
EPO is a managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).
Metal tier
Gold
Metal levels (which include bronze, silver, gold, and platinum) determine how you will split the cost of your healthcare services with your insurance carrier.
Bronze plans have the lowest monthly premiums and the highest costs when you need care
Silver plans have moderate monthly premiums and moderate costs when you need care.
Gold plans have high monthly premiums and low costs when you need care.
Platinum plans have the highest monthly premiums and the lowest costs when you need care.
Doctor visits
This can include any visits to your doctors (outside of regular checkups) within your plan's network.
The Physician Office Copayment may be reduced or waived when services are rendered by a Provider participating in the Quality Blue Program (QB). QB Providers include family practitioners, general practitioners, pediatricians, internists, geriatricians, nurse practitioners, and physician assistants, but more Providers may contract to participate in the Quality Blue program. The Physician Office Copayment may also be reduced or waived when services are rendered by a Provider participating in the Affinity Health Group.
This is the amount you’re responsible for when receiving primary care services.
For example, this could be an appointment with your primary care provider for a routine checkup or screening.
If you have a copayment plan, the Specialist copayment may be reduced or waived when services are rendered by an Affinity Health Group Provider.
This is the amount you’re responsible for when visiting a specialist (a medical professional who specializes in different types of diseases or conditions).
For example, a dermatologist, cardiologist, or pathologist.
Use the following Non-Grandfathered Preventive Care Services Brochure link for a complete list limitation and ages may vary: https://www.bcbsla.com/preventive Listed below is a sample of the Preventative/Screening/Immunization Benefits. Please refer to the member contract for more comprehensive list. EXAMINATIONS AND TESTING: Routine Wellness Physical Examination Certain routine wellness diagnostic tests ordered by Your Physician are covered. Well Baby Care; Prostate Cancer Screening; Colorectal Cancer Screening; IMMUNIZATION: All state mandated immunizations including the complete basic immunization series as defined by the state health officer and required for school entry for children up to age six (6) SCREENING AND COUNSELING: Abdominal Aortic Aneurysm Screening; Alcohol Misuse Screening and Counseling; Blood Pressure Screening; Cholesterol Screening; Depression Screening; Type 2 Diabetes Screening; Diet Counseling; HIV Screening; Obesity Screening and Counseling; Sexually Transmitted Infection Counseling; Tobacco Use Screening; Syphilis Screening; COVERED SERVICES FOR WOMEN: Counseling for - BRCA genetic testing and breast cancer chemoprevention; Routine Gynecologist / Obstetrician Visits; Mammography Examination; Osteoporosis Screening; Routine Pap Smear; Screening Chlamydia Infection and Gonorrhea; COVERED SERVICES FOR PREGNANT WOMEN: Anemia Screening; Bacteriuria Screening; Breast Feeding Intervention; Folic Acid Supplements; Hepatitis B Screening; Rh Incompatibility Screening; COVERED SERVICES FOR CHILDREN: Alcohol and Drug Use Assessments; Autism Screening; Behavioral Assessments; Cervical Dysplasia Screening; Congenital Hypothyroidism Screening; Developmental Screening; Dyslipidemia Screening Excludes: Any services not included in the following Non-Grandfathered Preventive Care Services Brochure link is excluded: https://www.bcbsla.com/preventive
There are dozens of preventive care services available for free with every plan, including check-ups, counseling, screenings, and immunizations
To learn more, scroll down to the Free Preventive Care section below.
Emergency / Surgery
These are the costs you’re responsible for in the case of an emergency or surgery.
An urgent care center can be a convenient option if you have a non-life-threatening injury and your doctor is not available.
Urgent care is usually less expensive than going to the Emergency Room, and will usually have shorter wait times for non-life-threatening injuries.
The ER copayment is waived if the visit results in an Inpatient Admission.
This is the amount you’re responsible for when receiving emergency room services.
Emergency Transportation/ Ambulance Includes but not limited to: To or from the nearest Hospital (when medically necessary); Benefits for air ambulance servcies are available only if this type of ambulance service is requested by policing or medical authorities at the site in an emergency situation or if the member is in a location that cannot be reached for a ground ambulance; Excludes: No benefits are available if transportation is provided for the Member's comfort or convenience, or when a hospital transports members between parts of its own campus.
This is the amount you’re responsible for when receiving ambulatory services.
Inpatient Bed, Board and General Nursing Services include but not limited to: 1. Hospital room and board and general nursing services. 2. In a Special Care Unit for a critically ill Member requiring an intensive level of care. 3. In a Skilled Nursing Facility or Unit or while receiving skilled nursing services in a Hospital, for the maximum number of days per Benefit Period shown in the Schedule of Benefits. 4. In a Residential Treatment Center for Members with Mental Disorders and Alcohol and/or Drug Abuse Benefits. B. Other Hospital Services (Inpatient and Outpatient) 1. Use of operating, delivery, recovery and treatment rooms and equipment. 2. Drugs and medicines including take-home Prescription Drugs. 3. Blood transfusions, including the cost of whole blood, blood plasma and expanders, processing charges, administrative charges, equipment and supplies. 4. Anesthesia, anesthesia supplies and anesthesia services rendered by a Hospital employee. 5. Medical and surgical supplies, casts, and splints. 6. Diagnostic Services rendered by a Hospital employee. 7. Physical Therapy provided by a Hospital employee. 8. Psychological testing when ordered by the attending Physician and performed by an employee of the hospital.
This is the amount you’re responsible for when using the facilities and equipment at a hospital.
Surgical services examples include but not limited to: 1. The Allowable Charge for Inpatient and Outpatient Surgery includes all pre-operative and postoperative medical visits. 2. Multiple Surgical Procedures - When Medically Necessary multiple procedures (concurrent, successive, or other multiple surgical procedures) are performed at the same surgical setting 3. Assistant Surgeon 4. General anesthesia services are covered when requested by the operating Physician and performed by a certified registered nurse anesthetist (CRNA) or Physician, other than the operating Physician or the assistant surgeon, for covered surgical services. Inpatient Medical Services - Subject to provisions in the sections pertaining to Surgery and Pregnancy Care in this Benefit Plan, Inpatient Medical Services include: 1. Inpatient medical care visits 2. Concurrent Care 3. Consultation (as defined in this Benefit Plan)
This is the amount you’re responsible for when receiving services provided by a physician, surgeon, medical doctor, or other specialist.
This is the amount you’re responsible for when using the equipment and facilities at a hospital.
Specifically, during a procedure that does not require overnight hospitalization.
Surgical services examples include but not limited to: 1. The Allowable Charge for Inpatient and Outpatient Surgery includes all pre-operative and postoperative medical visits. 2. Multiple Surgical Procedures - When Medically Necessary multiple procedures (concurrent, successive, or other multiple surgical procedures) are performed at the same surgical setting 3. Assistant Surgeon 4. General anesthesia services are covered when requested by the operating Physician and performed by a certified registered nurse anesthetist (CRNA) or Physician, other than the operating Physician or the assistant surgeon, for covered surgical services. Outpatient Medical and Surgical Services include: 1. Home, office, and other Outpatient visits for examination, diagnosis, and treatment of an illness or injury. Benefits for Outpatient medical services do not include separate payments for routine pre-operative and post-operative medical visits for Surgery or Pregnancy Care. 2. Services of an Ambulatory Surgical Center 3. Consultation (as defined in this Benefit Plan) Excludes: Exclusions include but not limited to: a. rhinoplasty; b. blepharoplasty services identified by CPT codes 15820, 15821, 15822, 15823; brow ptosis identified by CPT code 67900; or any revised or equivalent codes; c. gynecomastia; d. breast enlargement or reduction, except for breast reconstructive services as specifically provided in this Benefit Plan; e. implantation, removal and/or re-implantation of breast implants and services, illnesses, conditions, complications and/or treatment in relation to or as a result of breast implants; f. implantation, removal and/or re-implantation of penile prosthesis and services, illnesses, conditions, complications and/or treatment in relation to or as a result of penile prosthesis; g. diastasis recti; h. biofeedback; i. treatment related to erectile or sexual dysfunctions, low sexual desire disorder or other sexual inadequacies. j. Surgical and medical treatment for snoring in the absence of obstructive sleep apnea, including laser assisted uvulopalatoplasty (LAUP). k. Reversal of a voluntary sterilization procedure.
This is the amount you’re responsible for when receiving services provided by a physician, surgeon, or other specialist.
Specifically, during a procedure that does not require overnight hospitalization.
Rehabilitative Care Benefits will be available for Services provided on a Inpatient or Outpatient basis, including services for Occupational Therapy, Physical Therapy, Speech/Language Pathology Therapy, and/or Chiropractic Services.
This includes physical and occupational therapy, speech pathology, and psychiatric rehabilitation services.
Pregnancy
Every ACA health insurance plan covers healthcare services provided before and after your child is born. Here is a breakdown of the costs associated with your plan.
This is the amount you’re responsible for when receiving well baby care.
These services may include developmental screenings, counseling, behavioral assessments, plus more.
The Member must pay applicable Copayment, Deductible Amount and/or Coinsurance.
This is the amount you will pay for your labor, delivery, and hospital stay.
Prescriptions
Prescription coverage and cost is usually based on a tiered structure. These tiers are determined by generic, brand, or speciality drugs.
Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. All pharmacy plans have preventive drugs per USPSTF for $0. For 2-tier pharmacy plans, additional selected generic preventive care drugs in certain classes cost $0. For 3-tier and 4-tier pharmacy plans, additional selected drugs in certain classes used to treat selected chronic conditions cost $0. Excludes: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions.
This is the amount you will pay for a generic drug prescription.
Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. Note that for 3-tier and 4-tier plans, when a Brand-Name Drug is dispensed and a generic equivalent exists, Members must pay theTier 1 Drug Copayment amount, plus the difference in cost between the Brand-Name Drug dispensed and its generic equivalent. The Copayment for the Brand-Name Drug will not apply. The Members payment will apply to the Out-of-Pocket Amount. For 2-tier plans, the plan participant must pay the generic drug coinsurance, plus the difference in cost between the brand-name drug dispensed and its generic equivalent. Excludes: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions.
This is the amount you will pay for a brand name drug prescription.
Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. Note that for 3-tier and 4-tier plans, when a Brand-Name Drug is dispensed and a generic equivalent exists, Members must pay the Tier 1 Drug Copayment amount, plus the difference in cost between the Brand-Name Drug dispensed and its generic equivalent. The Copayment for the Brand-Name Drug will not apply. The Members payment will apply to the Out-of-Pocket Amount. For 2-tier plans, the plan participant must pay the generic drug coinsurance, plus the difference in cost between the brand-name drug dispensed and its generic equivalent. Excludes: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions.
This is the amount you will pay for a non-preferred brand name drug prescription.
Specialty drugs are distributed throughout all tiers including 2-tier, 3-tier, and 4-tier plans and the member is responsible to pay the applicable deductible/copay/coinsurance for that tier. Retail day supply limits (typically 30-day supply) apply. In addition, quantity per dispensing (QPD) limits/allowances are placed on certain specialty medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. Excludes: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions.
This is the amount you will pay for a speciality drug prescription.
Diagnostics / Labs / Imaging
This is the amount you're responsible for when receiving blood work, tests, or x-rays your doctor may need for diagnosing.
This is the amount you’re responsible for when having an x-ray.
This is the amount you’re responsible for when having an MRI, CET, PET scan.
This is the amount you’re responsible for when receiving blood work.
Mental health
Under the Affordable Care Act, all Marketplace plans are required to cover behavioral health treatment, mental and behavioral health inpatient services, as well as substance use treatment.
Office visits are covered same as primary care physician benefit. Excludes: Coverage for treatment of Mental Disorders does NOT include counseling services such as career counseling, marriage counseling, divorce counseling, parental counseling and job counseling. Education services and supplies including training or re-training for a vocation, except as specifically provided in this Benefit Plan for diagnosis, testing, or treatment for remedial reading and learning disabilities, including dyslexia.
This is the amount you’re responsible for when you have a procedure that does not require overnight hospitalization.
This is the amount you’re responsible for when you’re admitted or receiving treatment at a psychiatric hospital.
The Affordable Care Act requires that all health insurance plans cover preventive care for free. Preventive care services focus on managing and maintaining your health before something becomes serious. This includes routine check-ups, counseling, screenings, and immunizations. Grab our free guide to preventive care to refer back to later.
Abdominal aortic aneurysm one-time screening
For men of specified ages who have ever smoked
Free
Alcohol misuse screening and counseling
To prevent cardiovascular disease for men and women of certain ages
Free
Cholesterol screening
For adults of certain ages or at higher risk
Free
Colorectal cancer screening
For adults over 50
Free
Diabetes (Type 2) screening
For adults with high blood pressure
Free
Diet counseling
For adults at higher risk for chronic disease
Free
Hepatitis B screening
For people at high risk
Free
Hepatitis C screening
For adults at increased risk, and one time for everyone born 1945 – 1965
Free
HIV screening
For everyone ages 15 to 65, and other ages at increased risk
Free
Lung cancer screening
For adults 55 - 80 at high risk for lung cancer
Free
Syphilis screening
For adults at higher risk and all pregnant women
Free
Tobacco Use screening
For all adults and cessation interventions for tobacco users
Free
Official documents
If you'd like to see the official documents from the health insurance company, we've provided links to those here.
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