Blue Advantage Silver PPO℠ 204

Blue Cross and Blue Shield of Oklahoma · 2026 plan year

Silver

Ind. deductible: $200
Family deductible: $400
Ind. OOP max: $3,250
Family OOP max: $6,500

Other cost-sharing reduction variants for this plan:

73% AV Level Silver Plan 94% AV Level Silver Plan Limited Cost Sharing Plan Variation Standard Silver Off Exchange Plan Standard Silver On Exchange Plan Zero Cost Sharing Plan Variation

More Blue Cross and Blue Shield of Oklahoma plans in OK

Blue Advantage Gold PPO℠ 309 Blue Advantage Bronze PPO℠ Standard Blue Advantage Silver PPO℠ Standard Blue Advantage Gold PPO℠ Standard

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	$20.00

Specialist

Benefit	In-network
Specialist Visit	40.00% Coinsurance after deductible

Hospital

Benefit	In-network
Emergency Room Services	$500.00 Copay with deductible + 40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	$250.00 Copay per Stay with deductible + 40.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	$50.00 Copay with deductible + 40.00% Coinsurance after deductible
Urgent Care Centers or Facilities	40.00% Coinsurance after deductible

Pharmacy

Benefit	In-network
Generic Drugs	No Charge after deductible
Non-Preferred Brand Drugs	35.00% Coinsurance after deductible
Preferred Brand Drugs	20.00% Coinsurance after deductible
Specialty Drugs	45.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	$250.00 Copay per Stay with deductible + 40.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	40.00% Coinsurance after deductible

Other

Benefit	In-network
Orthodontia - Adult	Not covered
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	40.00% Coinsurance after deductible
Acupuncture	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	$250.00 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
Orthodontia - Child	Not covered
Other Practitioner Office Visit (Nurse, Physician Assistant)	40.00% Coinsurance after deductible
Emergency Transportation/Ambulance	40.00% Coinsurance after deductible
Eye Glasses for Children	No charge
Habilitation Services	40.00% Coinsurance after deductible
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	$50.00
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
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	$100.00 Copay with deductible + 30.00% Coinsurance after deductible
Outpatient Rehabilitation Services	40.00% Coinsurance after deductible
Prenatal and Postnatal Care	$20.00
Private-Duty Nursing	40.00% Coinsurance after deductible
Prosthetic Devices	40.00% Coinsurance after deductible
Radiation	40.00% Coinsurance after deductible
Reconstructive Surgery	40.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	40.00% Coinsurance after deductible
Rehabilitative Speech Therapy	40.00% Coinsurance after deductible
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	$250.00 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

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