Achieve Select Plan Details for 2020- HealthPocket

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Zip Code55106
Applicant2/18/1985 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameAchieve Select
Plan IDhhs-88102MN0210049
Plan Year2020
Insurance ProviderPreferredOne Insurance Company
Metal LevelExpanded Bronze
Plan TypePPO
Deductible$6,300
Out-of-Pocket Maximum$6,800
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness40.00% Coinsurance after deductible
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$12600 per group
Out-of-Pocket Maximum - Family$13600 per group

Prescription drug coverage

Generic Drugs40.00% Coinsurance after deductible
Preferred Brand Drugs60.00% Coinsurance after deductible
Specialty Drugs50.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttp://providerguide.preferredone.com/Default.asp?Network=OA300
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 - Applied to out of network benefits
Does this plan cover services outside the country?Yes - Emergency Only

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 CareNo Charge
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, 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
Cosmetic Surgery
Weight Loss Programs
Imaging (CT/PET Scans, MRIs)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Chiropractic Care
Routine Foot Care
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
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Congenital Anomaly, including Cleft Lip/Palate
Off Label Prescription Drugs
Port-Wine Stain Removal
Prescription Drugs Other
Services to Ventilator-Dependent Persons
Treatment of Lyme Disease
Genetic Testing
Biofeedback
Infertility Diagnosis
Routine Patient Cost for Clinical Trials
Testing for STD's
Treatment for STD's
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Treatment for children with emotional disorders
Insulin and other glucose lowering agents
More Limited BenefitsSkilled Nursing Facility
Hearing Aids
Private-Duty Nursing
Inpatient Physician and Surgical Services
Home Health Care Services
Hospice Services
Dental Check-Up for Children
More Excluded BenefitsAcupuncture
Bariatric Surgery
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Abortion for Which Public Funding is Prohibited
PremiumPlan NameDeductible
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Altru Prime by Medica Bronze H S A
$6,400.00Select
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  • Phone Number
    (651) 793-3100
  • Office Locations
    651 Arcade St
    Saint Paul, MN 55106
651 Arcade St Saint Paul MN, 55106

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).