2019 Gold PPO 2000/10/20 Plan Details - HealthPocket

Gold PPO 2000/10/20

$554.69/mo

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Zip Code19120
Applicant10/21/1984 Male
Coverage Start10/22/2019
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameGold PPO 2000/10/20
Plan IDhhs-45127PA0020013
Plan Year2019
Insurance ProviderCapital Blue Cross
Metal LevelGold
Plan TypePPO
Deductible$2,000
Out-of-Pocket Maximum$7,350
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$20 Copay
Specialist Visit$45 Copay
Laboratory Outpatient and Professional Services$25 Copay
X-rays and Diagnostic Imaging10.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans25.00% Coinsurance after deductible
Deductible - Family$4000 per group
Out-of-Pocket Maximum - Family$14700 per group

Prescription drug coverage

Generic Drugs$10 Copay
Preferred Brand Drugs$25 Copay after deductible
Non-Preferred Brand Drugs$75 Copay after deductible
Specialty Drugs40.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://www.capbluecross.com/wps/portal/cap/home/find/doctor
Does this plan have access to a national provider network?Yes
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?Yes - Out of Service Area services are covered in accordance with your certificate of coverage. Certain services may not be covered.
Does this plan cover services outside the country?Yes - Out of Country services are covered in accordance with your certificate of coverage. Certain services may not be covered.

Hospital services

Emergency Room Services$300 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)10.00% Coinsurance after deductible
Inpatient Physician and Surgical Services10.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service10.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity care10.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$45 Copay
Mental/Behavioral Health Inpatient Services10.00% Coinsurance after deductible
Substance use disorder outpatient services10.00% Coinsurance after deductible
Substance use disorder inpatient services10.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Depression, Diabetes, Heart Disease, Pregnancy
Does this plan offer a wellness program?Included

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareIncluded
Child Dental Coverage - Basic Dental CareIncluded
Child Dental Coverage - OrthodontiaIncluded
Child Dental Coverage - Major Dental CareIncluded

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Infertility Treatment
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Durable Medical Equipment
Hospice Services
Dental Anesthesia
Diabetes Care Management
Inherited Metabolic Disorder - PKU
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Well Baby Visits and Care
More Limited BenefitsSkilled Nursing Facility
Acupuncture
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Dental Check-Up for Children
Chiropractic Care
Nutritional Counseling
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsBariatric Surgery
Cosmetic Surgery
Hearing Aids
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Routine Foot Care
Non-Emergency Care When Traveling Outside the U.S.
Abortion for Which Public Funding is Prohibited
Treatment for Temporomandibular Joint Disorders
PremiumPlan NameDeductible
from $151
Shared Cost Blue PPO 2100 a Community Blue Plan
$2,100.00Select
from $151
Flex Blue PPO 2100 a Community Blue Plan
$2,100.00Select
from $179
Marketplace Extra 3
$2,000.00Select
from $234
Keystone HMO Silver
$2,000.00Select
from $256
Blue Cross, a Multi-State Plan
$2,000.00Select
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  • Phone Number
    (215) 324-2180
  • Office Locations
    448 E Wyoming Ave
    Philadelphia, PA 19120
448 E Wyoming Ave Philadelphia PA, 19120
  • What is the Gold Plan?

    ObamaCare’s Gold Plan is a type of Metal Plan on the Health Insurance Marketplace. Gold Plans qualify for Tax Credits, have high premiums, and good cost sharing. Gold plans mean higher premiums, less Tax Credits, but much better cost sharing on average than Silver or Bronze.

  • How are Gold Plans different than other Obamacare health plans?

    The fundamental difference among the new Obamacare health plans is the percentage of covered medical costs paid by the health plan. The Gold Plan typically pays 80% of covered medical costs.

  • How much does a Gold Plan cost?

    The monthly premium for a Gold Plan depends on the insurer from whom you purchase the plan, the number of people to be insured by the plan, your age, whether you smoke, and your geographic region. You can use HealthPocket’s comparison tool to compare Gold Plan premiums in your area.

  • When Can I Enroll in a Gold Plan?

    The Open Enrollment period for the 2018 Affordable Care Act health plans begins November 1, 2017 and ends December 15, 2017. See our Open Enrollment article for more information.

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).