(844) 967-1917
Blue Cross and Blue Shield of Oklahoma

Blue Advantage Gold PPO 309

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $1,200.00
  • Family: $3,600
  • Per Person: $1,200
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $8,700.00
  • Family: $17,400
  • Per Person: $8,700

Office Visit

Primary Doctor
  • CoPay: $25.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Specialist
  • CoPay: Not Applicable
  • CoInsurance: 25.00% Coinsurance after deductible
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered
  • Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.
  • Benefit Explanation: When prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 35.00% Coinsurance after deductible
  • Covered: Covered
  • Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.
  • Benefit Explanation: When prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.
Generic Drugs
  • CoPay: $5.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.
  • Benefit Explanation: Certain generic drugs may have a higher cost share amount than is listed on this page. When prescription drugs are bought from an out of network pharmacy additional charges may apply. See benefit book for details.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 45.00% Coinsurance after deductible
  • Covered: Covered
  • Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.
  • Benefit Explanation: Certain specialty drugs may have a higher cost share amount than is listed on this page. If prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

Inpatient Coverage

Hospital Services
  • CoPay: $400.00 Copay per Stay with deductible
  • CoInsurance: 25.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 25.00% Coinsurance after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: $950.00 Copay with deductible
  • CoInsurance: 25.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Member will be responsible for copay per emergency room admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Urgent Care Facility
  • CoPay: Not Applicable
  • CoInsurance: 25.00% Coinsurance after deductible
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: $400.00 Copay with deductible
  • CoInsurance: 25.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Pre and Postnatal Office Visit
  • CoPay: $25.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care.

Vision

Routine Eye Exams For Children
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per Benefit Period

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Not Covered
Routine Dental Checkups for Adults
  • Covered: Not Covered
  • HealthMarkets Insurance Agency d/b/a Insphere Insurance Solutions, 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.
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