Bronze HMO 8000/0/60 Plan Details for 2020- HealthPocket

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Zip Code19120
Applicant2/25/1985 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBronze HMO 8000/0/60
Plan IDhhs-53789PA0100008
Plan Year2020
Insurance ProviderCapital Blue Cross
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$8,000
Out-of-Pocket Maximum$8,150
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$60 Copay
Specialist Visit$85 Copay
Laboratory Outpatient and Professional Services$25 Copay
X-rays and Diagnostic ImagingNo Charge after deductible
Diagnostic Imaging such as MRIs, CT, and PET scansNo Charge after deductible
Deductible - Family$16000 per group
Out-of-Pocket Maximum - Family$16300 per group

Prescription drug coverage

Generic DrugsNo Charge after deductible
Preferred Brand DrugsNo Charge after deductible
Non-Preferred Brand DrugsNo Charge after deductible
Specialty Drugs50.00% Coinsurance

Access to doctors and hospitals

Provider directory URLhttps://www.capbluecross.com/wps/portal/cap/home/find/doctor
Does this plan have access to a national provider network?Yes
Is a referral required to see a Specialist?Yes - All except OB/GYN
Does this plan cover services outside plan service area?Yes - Emergent and Urgent
Does this plan cover services outside the country?Yes - Emergent and Urgent

Hospital services

Emergency Room ServicesNo Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)No Charge after deductible
Inpatient Physician and Surgical ServicesNo Charge after deductible
Emergency Transportation or Ambulance ServiceNo Charge after deductible

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity careNo Charge after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$85 Copay
Mental/Behavioral Health Inpatient ServicesNo Charge after deductible
Substance use disorder outpatient servicesNo Charge after deductible
Substance use disorder inpatient servicesNo Charge after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Depression, Diabetes, Heart Disease, Low Back Pain, Pregnancy
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 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
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
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsSkilled Nursing Facility
Acupuncture
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 BenefitsBariatric Surgery
Cosmetic Surgery
Hearing Aids
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Routine Foot Care
Non-Emergency Care When Traveling Outside the U.S.
Abortion for Which Public Funding is Prohibited
Treatment for Temporomandibular Joint Disorders
PremiumPlan NameDeductible
from $156
Together Blue Major Events EPO 8150 - 3 Free PCP Visits
$8,150.00Select
from $167
my Direct Blue Erie Major Events HMO 8150 - 3 Free PCP Visits
$8,150.00Select
from $180
UPMC Advantage Catastrophic $8,150/$0 - Partner Network
$8,150.00Select
from $186
Together Blue EPO Bronze 7900
$7,900.00Select
from $190
UPMC Advantage Catastrophic $8,150/$0 - Select Network
$8,150.00Select
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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

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).

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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).