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Blue Preferred Gold PPO℠ 205

87571OK0350198
Gold
PPO

Blue Preferred Gold PPO℠ 205 is a Gold PPO plan by Blue Cross and Blue Shield of Oklahoma.

IMPORTANT: You are viewing the 2024 version of Blue Preferred Gold PPO℠ 205 87571OK0350198. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Blue Preferred Gold PPO℠ 205 is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Blue Preferred Gold PPO℠ 205 87571OK0350198.
Insurer: Blue Cross and Blue Shield of Oklahoma
Network Type: PPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 87571OK0350198

Cost-Sharing Overview

Blue Preferred Gold PPO℠ 205 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Blue Preferred Gold PPO℠ 205?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Blue Preferred Gold PPO℠ 205 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Blue Preferred Gold PPO℠ 205 covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: 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.
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: When accessing care outside our service area, you will obtain care from healthcare Providers that have a contractual agreement (i.e., are Participating Providers) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (Host Blue). In some instances, you may obtain care from Non-Participating Providers.
National Network: Yes

Additional Benefits and Cost-Sharing

Blue Preferred Gold PPO℠ 205 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$60.00 Not ApplicableNot Applicable 30.00% Coinsurance after deductible
Specialist Visit
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
$300.00 Copay with deductible 20.00% Coinsurance after deductible$2000.00 Copay with deductible 50.00% Coinsurance after deductible Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. Member will be responsible for copay per outpatient surgery 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.
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Hospice Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible85.0 Visit(s) per Benefit Period
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$90.00 Not ApplicableNot Applicable 30.00% Coinsurance after deductible
Home Health Care Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible30.0 Visit(s) per Benefit Period
Emergency Room Services
Covered
$950.00 Copay with deductible 35.00% Coinsurance after deductible$950.00 Copay with deductible 35.00% Coinsurance after deductible 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.
Emergency Transportation/Ambulance
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Emergency Transportation/Ambulance is covered when your condition is such that an ambulance is necessary. Benefits will not be provided for long distance trips or for use of an ambulance because it is more convenient than other transportation when rendered in connection with a covered Inpatient admission or covered Emergency Accident Care or covered Emergency Medical Care or if it does not meet the definition of Medically Necessary for non-emergency medical situations. Benefits will not be provided for long distance trips. See benefit book for details.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
$400.00 Copay per Stay with deductible 35.00% Coinsurance after deductible$2000.00 Copay per Stay with deductible 50.00% Coinsurance after deductible 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 Physician and Surgical Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Cosmetic surgery is covered only for certain conditions. It is not covered for cosmetic surgery or complications resulting therefrom, including Surgery to improve or restore your appearance, unless needed to repair conditions resulting from an accidental injury; or for the improvement of the physiological functioning of a malformed body member resulting from a congenital defect. In no event will any care and services for breast reconstruction or implantation or removal of breast prostheses be a Covered Service unless such care and services are performed solely and directly as a result of mastectomy which is medically necessary.
Skilled Nursing Facility
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible30.0 Days per Benefit Period
Prenatal and Postnatal Care
Covered
$60.00 Not ApplicableNot Applicable 30.00% Coinsurance after deductible First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care.
Delivery and All Inpatient Services for Maternity Care
Covered
$400.00 Copay with deductible 35.00% Coinsurance after deductible$2000.00 Copay with deductible 50.00% Coinsurance after deductible Childbirth/delivery professional services are subject to your Medical EHB Deductible/Maximum Out of Pocket for Medical EHB benefits, if applicable. 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.
Mental/Behavioral Health Outpatient Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
Covered
$400.00 Copay per Stay with deductible 35.00% Coinsurance after deductible$2000.00 Copay per Stay with deductible 50.00% Coinsurance after deductible 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.
Substance Abuse Disorder Outpatient Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
$400.00 Copay per Stay with deductible 35.00% Coinsurance after deductible$2000.00 Copay per Stay with deductible 50.00% Coinsurance after deductible 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.
Generic Drugs
Covered
No Charge Not Applicable$10.00 Not Applicable 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. 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.
Preferred Brand Drugs
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible 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. 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
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible 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. 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.
Specialty Drugs
Covered
Not Applicable 45.00% Coinsurance after deductibleNot Applicable 45.00% Coinsurance after deductible 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. 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.
Outpatient Rehabilitation Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.
Habilitation Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.
Chiropractic Care
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.
Durable Medical Equipment
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Hearing Aids
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible 1 hearing aid per ear (2 hearing aids) every 48 months for any covered member.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Preventive Care/Screening/Immunization
Covered
No Charge Not ApplicableNot Applicable 30.00% Coinsurance after deductible
Routine Foot Care
Not Covered
Covered when medically necessary
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Visit(s) per Benefit Period When purchasing Out of Network, reimbursements are available. See benefit book for details
Eye Glasses for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Item(s) per Benefit Period Provider-designated frames are covered. An allowance may apply to non-provider-designated frames. Coinsurance may apply to non-provider-designated frames on the remaining balance over the allowance. See benefit book for details
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible25.0 Visit(s) per Benefit Period Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 30.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
X-rays and Diagnostic Imaging
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Accidental Dental
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Dialysis
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Allergy Testing
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Chemotherapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Radiation
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Diabetes Education
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Prosthetic Devices
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Infusion Therapy
Covered
$100.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Treatment for Temporomandibular Joint Disorders
Not Covered
Nutritional Counseling
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Covered when medically necessary
Reconstructive Surgery
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Breast reconstruction or implantation or removal of breast prostheses is a Covered Service only when performed solely and directly as a result of mastectomy which is Medically Necessary.
Gender Affirming Care
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible

Free Preventive Services

There is no copayment or coinsurance for any of the following Blue Preferred Gold PPO℠ 205 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Blue Preferred Gold PPO℠ 205 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Blue Preferred Gold PPO℠ 205?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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