Zip Code | 83709 |
Applicant | 1/26/1986 Male |
Insurance Type | ACA (Obamacare) |
Plan Name | SAHA Southwest Bronze Connect 8150 |
Plan ID | hhs-61589ID2360110 |
Plan Year | 2020 |
Insurance Provider | Blue Cross of Idaho |
Metal Level | Expanded Bronze |
Plan Type | POS |
Deductible | $8,150 |
Out-of-Pocket Maximum | $8,150 |
Plan Highlights |
Costs for Medical Care | |
---|---|
Primary Care Visit to Treat an Injury or Illness | $40 Copay |
Specialist Visit | $65 Copay |
Laboratory Outpatient and Professional Services | No Charge after deductible |
X-rays and Diagnostic Imaging | No Charge after deductible |
Diagnostic Imaging such as MRIs, CT, and PET scans | No Charge after deductible |
Deductible - Family | $16300 per group |
Out-of-Pocket Maximum - Family | $16300 per group |
Prescription drug coverage | |
---|---|
Generic Drugs | $15 Copay |
Preferred Brand Drugs | $35 Copay |
Non-Preferred Brand Drugs | $50 Copay |
Specialty Drugs | 50.00% Coinsurance |
Access to doctors and hospitals | |
---|---|
Provider directory URL | https://www.bcidaho.com/BCI_V2/prov_directory/prov_dir_criteria.aspx |
Does this plan have access to a national provider network? | Yes |
Is a referral required to see a Specialist? | Yes - Allergy/Immunology, Audiologist, Cardiology, Cardiothoracic Surgery, Colorectal Surgery, Dermatology, Endocrinology, ENT/Otolaryngology, Gastroenterology, General Surgery, Hand Surgery, Hepatologist, Infectious Disease, Nephrology, Neurology, Neurosurgery, Oncology/Hematology, Oral Surgery, Ophthalmology, Orthopedics, Pain Management, Perinatologist, Plastic Surgery, Podiatry, Proctology, Psychiatry, Pulmonology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery |
Does this plan cover services outside plan service area? | Yes - In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. |
Does this plan cover services outside the country? | Yes - The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply. |
Hospital services | |
---|---|
Emergency Room Services | No Charge after deductible |
Inpatient Hospital Services (e.g., Hospital Stay) | No Charge after deductible |
Inpatient Physician and Surgical Services | No Charge after deductible |
Emergency Transportation or Ambulance Service | No Charge after deductible |
Maternity | |
---|---|
Prenatal and Postnatal Care | No Charge after deductible |
Delivery and all inpatient services for maternity care | No Charge after deductible |
Mental Health | |
---|---|
Mental/Behavioral Health Outpatient Services | $40 Copay |
Mental/Behavioral Health Inpatient Services | No Charge after deductible |
Substance use disorder outpatient services | $40 Copay |
Substance use disorder inpatient services | No Charge after deductible |
Medical Management Programs | |
---|---|
Does this plan offer disease managment programs? | Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs |
Does this plan offer a wellness program? | Not Covered |
Vision Coverage | |
---|---|
Routine Eye Exam for Children | Included |
Eye Glasses for Children | Included |
Routine Eye Exam for Adults | Not Covered |
Child Dental Coverage | |
---|---|
Child Dental Coverage - Routine Dental Care | Not Covered |
Child Dental Coverage - Basic Dental Care | Not Covered |
Child Dental Coverage - Orthodontia | Not Covered |
Child Dental Coverage - Major Dental Care | Not Covered |
Adult Dental Coverage | |
---|---|
Adult Dental Coverage - Routine Dental Care | Not Covered |
Adult Dental Coverage - Basic Dental Care | Not Covered |
Adult Dental Coverage - Orthodontia | Not Covered |
Adult Dental Coverage - Major Dental Care | Not Covered |
Exclusions and Limitations | |
---|---|
More Included Benefits | Other Practitioner Office Visit (Nurse, Physician Assistant) Preventive Care/Screening/Immunization 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 Accidental Dental Allergy Testing Chemotherapy Diabetes Education Dialysis Infusion Therapy Laboratory Outpatient and Professional Services 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 Benefits | Skilled Nursing Facility Hearing Aids Outpatient Rehabilitation Services Habilitation Services Chiropractic Care Nutritional Counseling |
More Excluded Benefits | Acupuncture Bariatric Surgery Cosmetic Surgery Infertility Treatment Long-Term/Custodial Nursing Home Care Private-Duty Nursing Weight Loss Programs Dental Check-Up for Children Routine Foot Care Abortion for Which Public Funding is Prohibited Treatment for Temporomandibular Joint Disorders |
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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 Benefytt Technologies, Inc. family of companies.