2019 Silver PPO 4950/10/30 Plan Details - HealthPocket

Silver PPO 4950/10/30

$472.77/mo

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Zip Code19120
Applicant4/22/1984 Male
Coverage Start4/23/2019
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameSilver PPO 4950/10/30
Plan IDhhs-45127PA0020021
Plan Year2019
Insurance ProviderCapital Blue Cross
Metal LevelSilver
Plan TypePPO
Deductible$4,950
Out-of-Pocket Maximum$7,350
Personal Score

Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$30 Copay
Specialist Visit$75 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$9900 per group
Out-of-Pocket Maximum - Family$14700 per group

Prescription drug coverage

Generic Drugs$10 Copay
Preferred Brand Drugs$50 Copay after deductible
Non-Preferred Brand Drugs$100 Copay after deductible
Specialty Drugs50.00% 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$400 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$75 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
Abortion for Which Public Funding is Prohibited
Treatment for Temporomandibular Joint Disorders
PremiumPlan NameDeductible
from $184
Marketplace Solutions 9
$5,000.00Select
from $187
UPMC Advantage Enhanced Bronze Select
$5,000.00Select
from $191
Marketplace Direct 9
$5,000.00Select
from $200
UPMC Advantage Enhanced Bronze
$5,000.00Select
from $225
UPMC Advantage Premium Bronze
$5,000.00Select
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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 Silver Plan?

    ObamaCare’s Silver Plan is a type of Metal Plan on the Health Insurance Marketplace. Silver Plans qualify for both Tax Credits and Cost Sharing subsidies.Silver Plans have lower out-of-pocket costs than Bronze Plans but higher out- of-pocket costs than both Gold and Platinum Plans. All Silver Plans share the same minimum health benefits, but the way they charge out-of-pocket costs can differ significantly.

  • How are Silver 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 Silver Plan pays 70% of covered medical costs for a typical enrollee. Silver Plans are also the only metal plans which offer cost-sharing reduction (CSR) versions to consumers that require financial assistance for out-of-pocket costs.

  • How much does a Silver Plan cost?

    The monthly premium for a Silver 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 the region in which you live. You can use HealthPocket’s comparison tool to compare Silver Plan premiums in your area.

  • When Can I Enroll in a Silver 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, Medicaid or an individual 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 a wholly owned subsidiary of Health Plan Intermediaries Holdings LLC (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, Medicaid or an individual 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 a wholly owned subsidiary of Health Plan Intermediaries Holdings LLC (NASDAQ: HIIQ)