BlueChoice HMO HSA Bronze $4,000 Plan Details for 2020- HealthPocket

BlueChoice HMO HSA Bronze $4,000

$276.17/mo

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Zip Code21215
Applicant8/7/1985 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBlueChoice HMO HSA Bronze $4,000
Plan IDhhs-28137MD0370017
Plan Year2020
Insurance ProviderCareFirst BlueCross BlueShield
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$4,000
Out-of-Pocket Maximum$6,650
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$30 Copay after deductible
Specialist Visit$40 Copay after deductible
Laboratory Outpatient and Professional Services$25 Copay after deductible
X-rays and Diagnostic Imaging$55 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans$250 Copay after deductible
Deductible - Family$8000 per group
Out-of-Pocket Maximum - Family$13300 per group

Prescription drug coverage

Generic Drugs$10 Copay after deductible
Preferred Brand Drugs$50 Copay after deductible
Non-Preferred Brand Drugs$70 Copay after deductible
Specialty Drugs$150 Copay after deductible

Access to doctors and hospitals

Provider directory URLhttps://member.carefirst.com/mos/#/fappublic/search/standard?sType=M&planName=BlueChoice%20HMO
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?Yes - Emergency Services Only
Does this plan cover services outside the country?Yes - Emergency Services Only

Hospital services

Emergency Room Services$300 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)$500 Copay per Day after deductible
Inpatient Physician and Surgical Services$40 Copay after deductible
Emergency Transportation or Ambulance Service$40 Copay after deductible

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity care$500 Copay after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$30 Copay after deductible
Mental/Behavioral Health Inpatient Services$500 Copay per Day after deductible
Substance use disorder outpatient services$30 Copay after deductible
Substance use disorder inpatient services$500 Copay per Day 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, Pregnancy, Weight Loss Programs
Does this plan offer a wellness program?Included

Vision Coverage

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

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
Acupuncture
Bariatric Surgery
Infertility Treatment
Imaging (CT/PET Scans, MRIs)
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
Treatment for Temporomandibular Joint Disorders
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
Dental Check-Up for Children
Chiropractic Care
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsCosmetic Surgery
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Routine Foot Care
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  • Phone Number
    (410) 601-5209
  • Office Locations
    2401 W Belvedere Ave
    Baltimore, MD 21215
2401 W Belvedere Ave Baltimore MD, 21215

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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).