SimpliveraCoverage Companion

Blue Advantage Gold PPO℠ 309

Blue Cross and Blue Shield of Oklahoma · 2026 plan year

Gold
Ind. deductible
$1,050
Family deductible
$2,100
Ind. OOP max
$10,600
Family OOP max
$21,200

Other cost-sharing reduction variants for this plan:

Standard Gold Off Exchange PlanStandard Gold On Exchange PlanZero Cost Sharing Plan Variation

More Blue Cross and Blue Shield of Oklahoma plans in OK

Blue Advantage Silver PPO℠ 204Blue Advantage Gold PPO℠ 309Blue Advantage Bronze PPO℠ Standard

Live premium estimate

$

Benefits & cost sharing

Primary Care

BenefitIn-network
Preventive Care/Screening/ImmunizationNo charge
Primary Care Visit to Treat an Injury or Illness$25.00

Specialist

BenefitIn-network
Specialist Visit25.00% Coinsurance after deductible

Hospital

BenefitIn-network
Emergency Room Services$950.00 Copay with deductible + 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)$400.00 Copay per Stay with deductible + 25.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services25.00% Coinsurance after deductible
Urgent Care Centers or Facilities$40.00

Pharmacy

BenefitIn-network
Generic Drugs$5.00
Non-Preferred Brand Drugs35.00% Coinsurance after deductible
Preferred Brand Drugs30.00% Coinsurance after deductible
Specialty Drugs45.00% Coinsurance after deductible

Mental Health

BenefitIn-network
Mental/Behavioral Health Inpatient Services$400.00 Copay per Stay with deductible + 25.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services25.00% Coinsurance after deductible

Other

BenefitIn-network
Dental Check-Up for ChildrenNot covered
Abortion for Which Public Funding is ProhibitedNot covered
Accidental Dental25.00% Coinsurance after deductible
AcupunctureNot covered
Allergy Testing25.00% Coinsurance after deductible
Bariatric SurgeryNot covered
Basic Dental Care - AdultNot covered
Basic Dental Care - ChildNot covered
Chemotherapy25.00% Coinsurance after deductible
Chiropractic Care25.00% Coinsurance after deductible
Cosmetic SurgeryNot covered
Delivery and All Inpatient Services for Maternity Care$400.00 Copay with deductible + 25.00% Coinsurance after deductible
Diabetes Education25.00% Coinsurance after deductible
Dialysis25.00% Coinsurance after deductible
Durable Medical Equipment25.00% Coinsurance after deductible
Emergency Transportation/Ambulance25.00% Coinsurance after deductible
Eye Glasses for ChildrenNo charge
Habilitation Services25.00% Coinsurance after deductible
Hearing Aids25.00% Coinsurance after deductible
Home Health Care Services25.00% Coinsurance after deductible
Hospice Services25.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)15.00% Coinsurance after deductible
Infertility TreatmentNot covered
Infusion Therapy$100.00
Inpatient Physician and Surgical Services25.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services15.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home CareNot covered
Major Dental Care - AdultNot covered
Major Dental Care - ChildNot covered
Skilled Nursing Facility25.00% Coinsurance after deductible
Nutritional Counseling25.00% Coinsurance after deductible
Orthodontia - AdultNot covered
Orthodontia - ChildNot covered
Other Practitioner Office Visit (Nurse, Physician Assistant)25.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)15.00% Coinsurance after deductible
Outpatient Rehabilitation Services25.00% Coinsurance after deductible
Prenatal and Postnatal Care$25.00
Private-Duty Nursing25.00% Coinsurance after deductible
Prosthetic Devices25.00% Coinsurance after deductible
Radiation25.00% Coinsurance after deductible
Reconstructive Surgery25.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy25.00% Coinsurance after deductible
Rehabilitative Speech Therapy25.00% Coinsurance after deductible
Routine Dental Services (Adult)Not covered
Routine Eye Exam (Adult)Not covered
Routine Eye Exam for ChildrenNo charge
Routine Foot CareNot covered
Substance Abuse Disorder Inpatient Services$400.00 Copay per Stay with deductible + 25.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services25.00% Coinsurance after deductible
Transplant25.00% Coinsurance after deductible
Treatment for Temporomandibular Joint DisordersNot covered
Weight Loss ProgramsNot covered
Well Baby Visits and CareNo charge
X-rays and Diagnostic Imaging15.00% Coinsurance after deductible

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