my Direct Blue EPO Bronze 3900 Plan Details for 2020- HealthPocket

my Direct Blue EPO Bronze 3900

$346.99/mo

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Zip Code19120
Applicant6/1/1985 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan Namemy Direct Blue EPO Bronze 3900
Plan IDhhs-33709PA0870007
Plan Year2020
Insurance ProviderHighmark
Metal LevelExpanded Bronze
Plan TypeEPO
Deductible$3,900
Out-of-Pocket Maximum$7,900
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$60 Copay
Specialist Visit40.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services40.00% Coinsurance after deductible
X-rays and Diagnostic Imaging40.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans40.00% Coinsurance after deductible
Deductible - Family$7800 per group
Out-of-Pocket Maximum - Family$15800 per group

Prescription drug coverage

Generic Drugs40.00% Coinsurance after deductible
Preferred Brand Drugs40.00% 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.highmarkbcbs.com/find-a-doctor/#/home
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?No - The Plan covers only limited health care services received outside of the Network Service Area. As used in this Subsection, Out-of-Area Covered Services includes Emergency Care Services and Urgent Care Services obtained outside of the Network Service Area. Any other services will not be covered unless authorized by the Plan.
Does this plan cover services outside the country?Yes - Coverage is provided through the Blue Cross Blue Shield Global Core when a Member requires Emergency Care Services or Urgent Care Services while traveling or living outside the United States. All Emergency Care Services and Urgent Care Services are covered in accordance within the Member's Agreement.

Hospital services

Emergency Room Services40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)40.00% Coinsurance after deductible
Inpatient Physician and Surgical Services40.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service40.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care40.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care40.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services40.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services40.00% Coinsurance after deductible
Substance use disorder outpatient services40.00% Coinsurance after deductible
Substance use disorder inpatient services40.00% 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, 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 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 Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Outpatient Rehabilitation Services
Habilitation 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
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
Home Health Care Services
Dental Check-Up for Children
Chiropractic Care
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsAcupuncture
Bariatric 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
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from $195
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my Direct Blue Erie HMO Bronze 3900
$3,900.00Select
from $257
Together Blue EPO Silver 3950 HSA
$3,950.00Select
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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

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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).