Anthem Bronze X HMO 5000 for HSA Plan Details for 2020- HealthPocket

Anthem Bronze X HMO 5000 for HSA

$344.45/mo

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Zip Code04401
Applicant3/31/1985 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameAnthem Bronze X HMO 5000 for HSA
Plan IDhhs-48396ME0710044
Plan Year2020
Insurance ProviderAnthem BCBS
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$5,000
Out-of-Pocket Maximum$6,850
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness35.00% Coinsurance after deductible
Specialist Visit35.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services35.00% Coinsurance after deductible
X-rays and Diagnostic Imaging35.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans35.00% Coinsurance after deductible
Deductible - Family$10000 per group
Out-of-Pocket Maximum - Family$13700 per group

Prescription drug coverage

Generic Drugs35.00% Coinsurance after deductible
Preferred Brand Drugs35.00% Coinsurance after deductible
Non-Preferred Brand Drugs40.00% Coinsurance after deductible
Specialty Drugs40.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://www.anthem.com/health-insurance/provider-directory/searchcriteria?brand=abcbs
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Yes - All specialists require referral with the exception of OB/GYN
Does this plan cover services outside plan service area?No - TRAD/PAR network
Does this plan cover services outside the country?No - Urgent/Emergency Coverage Only

Hospital services

Emergency Room Services$250 Copay after deductible, 35.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Inpatient Hospital Services (e.g., Hospital Stay)35.00% Coinsurance after deductible
Inpatient Physician and Surgical Services35.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service35.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care35.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care35.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services35.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services35.00% Coinsurance after deductible
Substance use disorder outpatient services35.00% Coinsurance after deductible
Substance use disorder inpatient services35.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management
Does this plan offer a wellness program?Not Covered

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 CareNot Covered
Child Dental Coverage - Basic Dental CareNot Covered
Child Dental Coverage - OrthodontiaNot Covered
Child Dental Coverage - Major Dental CareNot Covered

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
Bariatric Surgery
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
Home Health Care Services
Durable Medical Equipment
Hospice Services
Abortion for Which Public Funding is Prohibited
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Well Baby Visits and Care
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsSkilled Nursing Facility
Hearing Aids
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsAcupuncture
Cosmetic Surgery
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Treatment for Temporomandibular Joint Disorders
PremiumPlan NameDeductible
from $295
Anthem Bronze X HMO 5000 for HSA
$5,000.00Select
from $306
Maines Choice HMO HSA Bronze 5000
$5,000.00Select
from $309
Anthem Bronze X HMO 5000 Online Plus
$5,000.00Select
from $345
Anthem Bronze HMO 5000 for HSA
$5,000.00Select
from $354
Maines Choice HMO HSA Bronze 5000
$5,000.00Select
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  • Phone Number
    (207) 907-3550
  • Office Locations
    360 Broadway Ste 100
    Bangor, ME 04401
360 Broadway Ste 100 Bangor ME, 04401

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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).