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Blue Advantage Bronze PPOSM 203
Plan Summary
Plan Type PPO
Metal Level Bronze
Office Visit for Primary Doctor
Find Doctors 		40% Coinsurance after deductible
Office Visit for Specialist 40% Coinsurance after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) 40% Coinsurance after deductible
Annual Deductible Individual: $4,500
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 40%
Retail Prescription Drugs Generic Drugs: 20% Coinsurance after deductible;
Preferred Brand Drugs: 30% Coinsurance after deductible;
Non-Preferred Brand Drugs: 35% Coinsurance after deductible;
Specialty Drugs: 45% Coinsurance after deductible;
Annual Out-of-Pocket Limit Individual: $7,500
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage Yes. This plan does not cover any services and/or supplies provided to a member outside of the United States, if the member traveled to the location for the purposes of receiving medical services, supplies, or drugs. 
Office Visit
Primary Care Physician Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room $950 Copay with deductible, then 40% Coinsurance after deductible
Emergency Ambulance Services 40% Coinsurance after deductible
Urgent Care Facility 40% Coinsurance after deductible
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: 20% Coinsurance after deductible;
Preferred Brand Drugs: 30% Coinsurance after deductible;
Non-Preferred Brand Drugs: 35% Coinsurance after deductible;
Specialty Drugs: 45% Coinsurance after deductible;
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Outpatient Surgery Physician/Surgical Services:
$200 Copay with deductible, then 40% Coinsurance after deductible
Outpatient Facility Fee:
$300 Copay with deductible, then 30% Coinsurance after deductible
Outpatient Lab/X-Ray Outpatient Lab:
30% Coinsurance after deductible
X-rays:
30% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) 30% Coinsurance after deductible
Outpatient Mental Health 40% Coinsurance after deductible
Outpatient Substance Abuse 40% Coinsurance after deductible
Outpatient Rehabilitation Services (PT, OT, ST) 40% Coinsurance after deductible, limited to 25 Visit(s) per Benefit Period
Inpatient Coverage
Hospitalization Inpatient Hospital Services:
$400 Copay per Stay with deductible, then 40% Coinsurance after deductible
Inpatient Physician and Surgical Services:
40% Coinsurance after deductible
Skilled Nursing Facility 40% Coinsurance after deductible, limited to 30 Days per Benefit Period
Inpatient Mental Health $400 Copay per Stay with deductible, then 40% Coinsurance after deductible
Inpatient Substance Abuse $400 Copay per Stay with deductible, then 40% Coinsurance after deductible
Home Healthcare 40% Coinsurance after deductible, limited to 30 Visit(s) per Benefit Period
Maternity Coverage
Pre & Postnatal Office Visit 40% Coinsurance after deductible
Labor & Delivery Hospital Stay $400 Copay with deductible, then 40% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children No Charge after deductible, limited to 1 Visit(s) per Benefit Period
Eye Glasses for Children No Charge after deductible, limited to 1 Item(s) per Benefit Period
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage 40% Coinsurance after deductible, limited to 25 Visit(s) per Benefit Period
Durable Medical Equipment 40% Coinsurance after deductible
Hospice 40% Coinsurance after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required No
Out-of-Network Annual Deductible $13500 per person | $27000 per group
Out-of-Network Annual Coinsurance 50%
Out-of-Network Annual Out-of-Pocket Limit per person not applicable | per group not applicable
Additional Information
A.M. Best Rating A+ as of 10/31/2024
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • - EHealthInsurance Services, Inc. is an independent, authorized agent for Blue Cross and Blue Shield of Oklahoma.

    Blue Cross and Blue Shield of Oklahoma: A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

    Effective dates are available on the first of the month only, unless otherwise required by law. Applications must be received by Blue Cross and Blue Shield of Oklahoma within the defined enrollment period to be accepted.
  • - EHealthInsurance offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.