Personal Choice PPO Gold Plan Details for 2021- HealthPocket
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Personal Choice PPO Gold

$672.56/mo
View BrochureSummary of BenefitsProvider Directory

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Zip Code19120
Applicant1/16/1986 Male

Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NamePersonal Choice PPO Gold
Plan IDhhs-31609PA0190002
Plan Year2020
Insurance ProviderIndependence Blue Cross
Metal LevelGold
Plan TypePPO
Deductible$0
Out-of-Pocket Maximum$7,000
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$30 Copay
Specialist Visit$65 Copay
Laboratory Outpatient and Professional ServicesNo Charge
X-rays and Diagnostic Imaging$60 Copay
Diagnostic Imaging such as MRIs, CT, and PET scans$120 Copay
Deductible - Family$0 per group
Out-of-Pocket Maximum - Family$14000 per group

Prescription drug coverage

Generic Drugs$15 Copay
Preferred Brand Drugs40.00% Coinsurance
Non-Preferred Brand Drugs50.00% Coinsurance
Specialty Drugs50.00% Coinsurance

Access to doctors and hospitals

Provider directory URLhttp://www.ibx.com/providerfinder
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 - Coverage is provided for benefits received anywhere in the U.S.
Does this plan cover services outside the country?Yes - Coverage is provided for benefits received while outside of the U.S.

Hospital services

Emergency Room Services$350 Copay
Inpatient Hospital Services (e.g., Hospital Stay)$750 Copay per Day
Inpatient Physician and Surgical Services20.00% Coinsurance
Emergency Transportation or Ambulance Service$100 Copay

Maternity

Prenatal and Postnatal Care$65 Copay
Delivery and all inpatient services for maternity care$750 Copay

Mental Health

Mental/Behavioral Health Outpatient Services$65 Copay
Mental/Behavioral Health Inpatient Services$750 Copay per Day
Substance use disorder outpatient services$65 Copay
Substance use disorder inpatient services$750 Copay per Day

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pregnancy
Does this plan offer a wellness program?Not Covered

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 Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Durable Medical Equipment
Hospice Services
Dental Anesthesia
Diabetes Care Management
Inherited Metabolic Disorder - PKU
Abortion for Which Public Funding is Prohibited
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Well Baby Visits and Care
Telemedicine
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsSkilled Nursing Facility
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Dental Check-Up for Children
Chiropractic Care
Nutritional Counseling
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
Treatment for Temporomandibular Joint Disorders
PremiumPlan NameDeductible
from $360Ambetter Balanced Care 207 (2021)$0.00Select
from $376Keystone HMO Silver Proactive Select$0.00Select
from $381Oscar Bronze Classic Next ($3 Prescription List + Free 24/7 Vir$100.00Select
from $382Ambetter Balanced Care 207 (2021) + Vision + Adult Dental$0.00Select
from $450Keystone HMO Silver Proactive$0.00Select
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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

  • What is the Gold Plan?

    ObamaCare’s Gold Plan is a type of Metal Plan on the Health Insurance Marketplace. Gold Plans qualify for Tax Credits, have high premiums, and good cost sharing. Gold plans mean higher premiums, less Tax Credits, but much better cost sharing on average than Silver or Bronze.

  • How are Gold Plans different than other Obamacare health plans?

    The fundamental difference among the new Obamacare health plans is the percentage of covered medical costs paid by the health plan. The Gold Plan typically pays 80% of covered medical costs.

  • How much does a Gold Plan cost?

    The monthly premium for a Gold Plan depends on the insurer from whom you purchase the plan, the number of people to be insured by the plan, your age, whether you smoke, and your geographic region. You can use HealthPocket’s comparison tool to compare Gold Plan premiums in your area.

  • When Can I Enroll in a Gold Plan?

    The Open Enrollment period for the 2018 Affordable Care Act health plans begins November 1, 2017 and ends December 15, 2017. See our Open Enrollment article for more information.

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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.

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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 Benefytt Technologies, Inc. family of companies.