BLUE MAX PPO – Blue Cross Blue Shield of Louisiana –
A comparison of the BLUE MAX PPO offered by
Blue Cross Blue Shield of Louisiana
is detailed out below for both Network and Non-Network coverage.
Network
Non-Network
Copay
$50
50% after deductible
OfficeVisit
$50
Subject to deductible and coinsurance.
Deductible
Coinsurance
70%
50%
Coinsurance Limit
Out-of-Pocket Maximum
Lifetime Maximum
Unlimited
Unlimited
Prescription Drugs
Separate $500 prescription drug deductible applies (member must meet the prescription deductible before any prescription drug benefits are payable) Generic drugs (and certain brand-name drugs)- $7; Brand-name drugs (and certain generic drugs)- $25; Generic or brand-name drugs with a therapeutic alternative- $45; Multi-Source Brand drugs- $60; Injectables- $50; For retail pharmacies, the copayment covers up to a 30-day supply; Mail-order services are also available. When ordering drugs by mail, you pay three copayments and receive up to a 90-day supply. A separate copayment is required for each dispensing you receive
Separate $500 prescription drug deductible applies (member must meet the prescription deductible before any prescription drug benefits are payable) Generic drugs (and certain brand-name drugs)- $7; Brand-name drugs (and certain generic drugs)- $25; Generic or brand-name drugs with a therapeutic alternative- $45; Multi-Source Brand drugs- $60; Injectables- $50; For retail pharmacies, the copayment covers up to a 30-day supply; Mail-order services are also available. When ordering drugs by mail, you pay three copayments and receive up to a 90-day supply. A separate copayment is required for each dispensing you receive
Emergency Room
Subject to deductible and coinsurance.
Subject to deductible and coinsurance.
Adult Preventative Care
Covered 100%- One routine Pap smear per calendar year, One routine physical per benefit period, One mammography exam per benefit period, One routine colon (hemoccult) test per calendar year, One routine gynecological exam per calendar year, and One prostate (PSA) screening test and one digital rectal exam per calendar year for members age 50 and older, or more frequently if recommended by physician.
Subject to deductible and coinsurance.
Child Preventative Care
Covered 100%- Routine pediatric exams and all immunizations.
Subject to deductible and coinsurance.
Lab / X-Ray
Subject to deductible and coinsurance.
Subject to deductible and coinsurance.
Maternity
Optional Benefit- Subject to deductible and coinsurance
Optional Benefit- Subject to deductible and coinsurance
Physical Therapy
Subject to deductible and coinsurance; Limited to $4,500 combined maximum each Benefit Period.
Subject to deductible and coinsurance; Limited to $4,500 combined maximum each Benefit Period.
