Providence Engineering - 2023 Benefits Guide
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MEDICAL INSURANCE<br />
CARRIER:: Blue Cross Blue Shield of Louisiana<br />
Please refer to the official plan documents for additional information on coverage and exclusions.<br />
Click Link for Video: HDHP PPO Copay<br />
COVERED BENEFITS<br />
Blue Saver<br />
Premier Blue<br />
Individual Family Individual Family<br />
In-Network Deductible $2,000 $4,000 $1,200 $3,000<br />
Annual Out-of-Pocket Maximum $4,400 $8,800 $4,500 $8,000<br />
Lifetime Maximum Unlimited Unlimited<br />
Primary Services Deductible + 20% $30 Copay<br />
Specialist Physician Office Visit Deductible + 20% $50 Copay<br />
Preventive Care Services Covered at 100% Covered at 100%<br />
Urgent Care Center Deductible + 20% $100 Copay<br />
Hospital Services<br />
Emergency Room Deductible + 20% $150 Copay<br />
Outpatient Facility Deductible + 20% Deductible + 20%<br />
MRI, CT, MRA, and PET Deductible + 20% Deductible + 20%<br />
Severe Mental/Nervous<br />
Inpatient Deductible + 20% Deductible + 20%<br />
Outpatient Deductible + 20% $30 Copay<br />
Prescription Drug <strong>Benefits</strong><br />
Deductible Embedded with Medical $0<br />
Tier I (Generic) Deductible + 0% $7 Copay<br />
Tier II (Preferred Brand) Deductible + 20% $35 Copay<br />
Tier III (Non-Preferred Brand) N/A $100 Copay<br />
Tier IV (Specialty) N/A 20% up to $250/per Rx<br />
Pharmacy Tier Review: Bcbsla.com/covered drugs<br />
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