MyBlue Bronze HMO℠ 904
Blue Cross and Blue Shield of Oklahoma · 2026 plan year
BronzeHSA eligible
- Ind. deductible
- $4,500
- Family deductible
- $9,000
- Ind. OOP max
- $10,150
- Family OOP max
- $20,300
Compare with other Bronze plans in OK
Side by side: deductibles, out-of-pocket limits and copays.
Other cost-sharing reduction variants for this plan:
More Blue Cross and Blue Shield of Oklahoma plans in OK
Monthly premiums by age
Rating Area 3
| Age | Individual | Individual + tobacco |
|---|---|---|
| Under 15 | $333 | $333 |
| 21 | $435 | $435 |
| 30 | $494 | $560 |
| 40 | $556 | $717 |
| 50 | $777 | $1,028 |
| 60 | $1,181 | $1,518 |
| 64 and over | $1,306 | $1,678 |
Live premium estimate
Benefits & cost sharing
Primary Care
| Benefit | In-network |
|---|---|
| Preventive Care/Screening/Immunization | No charge |
| Primary Care Visit to Treat an Injury or Illness | $50.00 |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | 40.00% Coinsurance after deductible |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | $950.00 Copay with deductible + 40.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay) | $400.00 Copay per Stay with deductible + 40.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services | $200.00 Copay with deductible + 40.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities | 40.00% Coinsurance after deductible |
Pharmacy
| Benefit | In-network |
|---|---|
| Generic Drugs | 20.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs | 35.00% Coinsurance after deductible |
| Preferred Brand Drugs | 30.00% Coinsurance after deductible |
| Specialty Drugs | 45.00% Coinsurance after deductible |
Mental Health
| Benefit | In-network |
|---|---|
| Mental/Behavioral Health Inpatient Services | $400.00 Copay per Stay with deductible + 40.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services | 40.00% Coinsurance after deductible |
Other
| Benefit | In-network |
|---|---|
| Accidental Dental | 40.00% Coinsurance after deductible |
| Acupuncture | Not covered |
| Prosthetic Devices | 40.00% Coinsurance after deductible |
| Radiation | 40.00% Coinsurance after deductible |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Allergy Testing | 40.00% Coinsurance after deductible |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Chemotherapy | 40.00% Coinsurance after deductible |
| Chiropractic Care | 40.00% Coinsurance after deductible |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | $400.00 Copay with deductible + 40.00% Coinsurance after deductible |
| Dental Check-Up for Children | Not covered |
| Diabetes Education | 40.00% Coinsurance after deductible |
| Dialysis | 40.00% Coinsurance after deductible |
| Durable Medical Equipment | 40.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 40.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Habilitation Services | $50.00 |
| Hearing Aids | 40.00% Coinsurance after deductible |
| Home Health Care Services | 40.00% Coinsurance after deductible |
| Hospice Services | 40.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 30.00% Coinsurance after deductible |
| Infertility Treatment | Not covered |
| Infusion Therapy | $100.00 |
| Inpatient Physician and Surgical Services | 40.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | 30.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Nutritional Counseling | 40.00% Coinsurance after deductible |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | 40.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $300.00 Copay with deductible + 30.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $50.00 |
| Prenatal and Postnatal Care | $50.00 |
| Private-Duty Nursing | 40.00% Coinsurance after deductible |
| Reconstructive Surgery | 40.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $50.00 |
| Rehabilitative Speech Therapy | $50.00 |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | Not covered |
| Skilled Nursing Facility | 40.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | $400.00 Copay per Stay with deductible + 40.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | 40.00% Coinsurance after deductible |
| Transplant | 40.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | Not covered |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 30.00% Coinsurance after deductible |
Plan rules
Service area
This plan covers 5 geographic areas.
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