Personal Choice EPO Bronze Reserve Plan Details for 2021- HealthPocket

ZIP Code
County
Applicant Info
Applicant
Date of birth
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Gender
male
female
Income
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Zip Code	19120 (edit)
Applicant	4/14/1986 Male (edit)

Insurance Type	ACA (Obamacare)
Plan Name	Personal Choice EPO Bronze Reserve
Plan ID	qhp-31609PA0160005
Plan Year	2020
Insurance Provider	Independence Blue Cross
Metal Level	Expanded Bronze
Plan Type	EPO
Deductible	$6,900
Out-of-Pocket Maximum	$6,900
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	No Charge after Deductible
Specialist Visit	No Charge after Deductible
Laboratory Outpatient and Professional Services	No Charge after deductible
X-rays and Diagnostic Imaging	No Charge after deductible
Deductible - Family	$13800
Out-of-Pocket Maximum - Family	$13800

Prescription drug coverage
Generic Drugs	No Charge after Deductible
Preferred Brand Drugs	No Charge after Deductible
Non-Preferred Brand Drugs	No Charge after Deductible
Specialty Drugs	No Charge after Deductible

Access to doctors and hospitals
Provider directory URL	http://www.ibx.com/individuals/find_provider/index.html

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

Maternity
Prenatal and Postnatal Care	No Charge after deductible

Mental Health
Mental/Behavioral Health Outpatient Services	No Charge after deductible
Mental/Behavioral Health Inpatient Services	No Charge after deductible

Vision Coverage
Routine Eye Exam for Children	No Charge
Eye Glasses for Children	No Charge

Exclusions and Limitations
More Included Benefits	Reconstructive Surgery Dental Anesthesia Inherited Metabolic Disorder - PKU Telemedicine Diabetes Care Management Other Practitioner Office Visit (Nurse, Physician Assistant) Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Services Hospice Services Infertility Treatment Urgent Care Centers or Facilities Home Health Care Services Inpatient Physician and Surgical Services Skilled Nursing Facility Outpatient Rehabilitation Services Habilitation Services Chiropractic Care Durable Medical Equipment Imaging (CT/PET Scans, MRIs) Preventive Care/Screening/Immunization Dental Check-Up for Children Rehabilitative Speech Therapy Rehabilitative Occupational and Rehabilitative Physical Therapy Well Baby Visits and Care Transplant Accidental Dental Dialysis Allergy Testing Chemotherapy Radiation Diabetes Education Prosthetic Devices Infusion Therapy Nutritional Counseling
More Excluded Benefits	Long-Term/Custodial Nursing Home Care Private-Duty Nursing Bariatric Surgery Cosmetic Surgery Hearing Aids Routine Foot Care Acupuncture Weight Loss Programs Abortion for Which Public Funding is Prohibited Treatment for Temporomandibular Joint Disorders

Exclusions and Limitations

More Included Benefits

Reconstructive Surgery
Dental Anesthesia
Inherited Metabolic Disorder - PKU
Telemedicine
Diabetes Care Management
Other Practitioner Office Visit (Nurse, Physician Assistant)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Hospice Services
Infertility Treatment
Urgent Care Centers or Facilities
Home Health Care Services
Inpatient Physician and Surgical Services
Skilled Nursing Facility
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Imaging (CT/PET Scans, MRIs)
Preventive Care/Screening/Immunization
Dental Check-Up for Children
Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Well Baby Visits and Care
Transplant
Accidental Dental
Dialysis
Allergy Testing
Chemotherapy
Radiation
Diabetes Education
Prosthetic Devices
Infusion Therapy
Nutritional Counseling

More Excluded Benefits

Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Bariatric Surgery
Cosmetic Surgery
Hearing Aids
Routine Foot Care
Acupuncture
Weight Loss Programs
Abortion for Which Public Funding is Prohibited
Treatment for Temporomandibular Joint Disorders

+ See All Coverage Details

Premium	Plan Name	Deductible
from $292	UPMC Advantage Bronze $6,700/$0 - Standard Network	$6,700.00	Select
from $320	Ambetter Essential Care 2 HSA (2021)	$6,900.00	Select
from $339	Ambetter Essential Care 2 HSA (2021) + Vision + Adult Dental	$6,900.00	Select
from $362	Personal Choice EPO Bronze Reserve	$7,000.00	Select
from $490	Oscar Silver Classic Copay ($3 Prescription List + Free 24/7 Vi	$7,000.00	Select

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Kenneth, Nguyen

Personal Choice EPO Bronze Reserve

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Benefits & Coverage

Costs for Medical Care

Prescription drug coverage

Access to doctors and hospitals

Hospital services

Maternity

Mental Health

Vision Coverage

Exclusions and Limitations

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