BasicBlue Direct 6450/12900 WOPDAcu Plan Details for 2020- HealthPocket

BasicBlue Direct 6450/12900 WOPDAcu

$313.60/mo

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Zip Code02909
Applicant4/3/1985 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBasicBlue Direct 6450/12900 WOPDAcu
Plan IDhhs-15287RI1200003
Plan Year2020
Insurance ProviderBlue Cross Blue Shield of Rhode Island
Metal LevelExpanded Bronze
Plan TypePPO
Deductible$6,450
Out-of-Pocket Maximum$7,350
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$30 Copay
Specialist Visit$60 Copay
Laboratory Outpatient and Professional Services10.00% Coinsurance after deductible
X-rays and Diagnostic Imaging10.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans10.00% Coinsurance after deductible
Deductible - Family$12900 per group
Out-of-Pocket Maximum - Family$14700 per group

Prescription drug coverage

Generic Drugs$35 Copay
Preferred Brand Drugs$50 Copay after deductible
Non-Preferred Brand Drugs$100 Copay after deductible
Specialty Drugs$100 Copay after deductible

Access to doctors and hospitals

Provider directory URLhttps://www.bcbsri.com/finddoctor
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 - For BlueCard Access call 1-800-810-BLUE (2583) or visit the BlueCard PPO Doctor and Hospital finder web page at www.bcbs.com.
Does this plan cover services outside the country?No - Coverage for urgent or emergent care only.

Hospital services

Emergency Room Services10.00% Coinsurance 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 Service$50 Copay

Maternity

Prenatal and Postnatal Care10.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care10.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$50 Copay
Mental/Behavioral Health Inpatient Services10.00% Coinsurance after deductible
Substance use disorder outpatient services$50 Copay
Substance use disorder inpatient services10.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, High Blood Pressure & High Cholesterol
Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsIncluded

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)
Skilled Nursing Facility
Bariatric Surgery
Hearing Aids
Private-Duty Nursing
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
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Hospice Services
Routine Foot Care
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
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Well Baby Visits and Care
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsPreventive Care/Screening/Immunization
Acupuncture
Infertility Treatment
Chiropractic Care
More Excluded BenefitsCosmetic Surgery
Long-Term/Custodial Nursing Home Care
Weight Loss Programs
Dental Check-Up for Children
Treatment for Temporomandibular Joint Disorders
PremiumPlan NameDeductible
from $313
BasicBlue Direct WOPD 6450/12900
$6,450.00Select
from $314
BasicBlue Direct WPD 6450/12900
$6,450.00Select
from $314
BasicBlue Direct 6450/12900 WPDAcu
$6,450.00Select
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  • Phone Number
    (401) 444-0540
  • Office Locations
    100 Curtis St
    Providence, RI 02909
100 Curtis St Providence RI, 02909

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HealthPocket.com provides information on insurance products. If you choose to obtain a quote or apply for an insurance plan, you may be transferred to a partner website to complete your request. Always review the privacy and terms of use of the partner website.

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).