Blue Saver Bronze Plan Details for 2021- HealthPocket

ZIP Code
County
Applicant Info
Applicant
Date of birth
//
Gender
male
female
Income
$

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Zip Code	35215 (edit)
Applicant	4/21/1986 Male (edit)

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Insurance Type	ACA (Obamacare)
Plan Name	Blue Saver Bronze
Plan ID	hhs-46944AL0460001
Plan Year	2021
Insurance Provider	Blue Cross Blue Shield of Alabama
Metal Level	Expanded Bronze
Plan Type	PPO
Deductible	$7,750
Out-of-Pocket Maximum	$7,750
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
Diagnostic Imaging such as MRIs, CT, and PET scans	No Charge after deductible
Deductible - Family	$15500 per group
Out-of-Pocket Maximum - Family	$15500 per group

Prescription drug coverage
Generic Drugs	$20 Copay
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	https://www.bcbsal.org/web/provider-finder
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 - If a PPO provider is used, same benefits as PPO in service area apply. If non-PPO provider is used, member may be responsible for filing claims and out-of-network benefits would be applicable.
Does this plan cover services outside the country?	Yes - If a PPO provider is used, same benefits as PPO in country apply. If non-PPO provider is used, member is responsible for filing claims and out-of-network benefits would be applicable.

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
Emergency Transportation or Ambulance Service	No Charge after deductible

Maternity
Prenatal and Postnatal Care	No Charge after deductible
Delivery and all inpatient services for maternity 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
Substance use disorder outpatient services	No Charge after deductible
Substance use disorder inpatient services	No Charge after deductible

Medical Management Programs
Does this plan offer disease managment programs?	Asthma, Diabetes, Heart Disease, Pregnancy
Does this plan offer a wellness program?	Included

Vision Coverage
Routine Eye Exam for Children	Included
Eye Glasses for Children	Included
Routine Eye Exam for Adults	Not Covered

Child Dental Coverage
Child Dental Coverage - Routine Dental Care	Included
Child Dental Coverage - Basic Dental Care	Included
Child Dental Coverage - Orthodontia	Included
Child Dental Coverage - Major Dental Care	Included

Adult Dental Coverage
Adult Dental Coverage - Routine Dental Care	Not Covered
Adult Dental Coverage - Basic Dental Care	Not Covered
Adult Dental Coverage - Orthodontia	Not Covered
Adult Dental Coverage - Major Dental Care	Not Covered

Exclusions and Limitations
More Included Benefits	Other 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 Home Health Care Services Durable Medical Equipment Hospice Services Non-Emergency Care When Traveling Outside the U.S. Accidental Dental Allergy Testing Chemotherapy Dialysis Infusion Therapy Laboratory Outpatient and Professional Services Prosthetic Devices Radiation Reconstructive Surgery Transplant Treatment for Temporomandibular Joint Disorders Well Baby Visits and Care Off Label Prescription Drugs Telephone and Online Video Physician Consultation Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited Benefits	Outpatient Rehabilitation Services Habilitation Services Dental Check-Up for Children Chiropractic Care Diabetes Education Rehabilitative Occupational and Rehabilitative Physical Therapy Rehabilitative Speech Therapy Air Ambulance
More Excluded Benefits	Skilled Nursing Facility Acupuncture Bariatric Surgery Cosmetic Surgery Hearing Aids Long Term Care Private-Duty Nursing Weight Loss Programs Routine Foot Care Dental Care - Adult Abortion for Which Public Funding is Prohibited Nutritional Counseling Long-Term/Custodial Nursing Home Care

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Last Name

Location/Distance

Please select the correct zip

Deborah, Peters

Michael, Powell

Rebecca, Dailey

Russell, Marsh

Fredred, Jones

Jsg Medical

Jeffrey, Jackson

Russell, Berry

Ann, Collins

Klayton, Barrows

Gary, Hodge

Phillip, Higginbotham

Andrew, Wilkins

Giuseppe, La Spina

Keonna, Farmer

Matthew, Mabery

Anna, Worth

Adam, Johnston

Christ Health Center Inc

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Hyewon, Lim

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Deborah Peters, MD

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Phone Number
(205) 833-6888
Office Locations
9772 Parkway E
Birmingham, AL 35215

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ZIP Code
County
Applicant Info
Applicant
Date of birth
//
Gender
male
female
Income
$

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Blue Saver Bronze

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Benefits & Coverage

Costs for Medical Care

Prescription drug coverage

Access to doctors and hospitals

Hospital services

Maternity

Mental Health

Medical Management Programs

Vision Coverage

Child Dental Coverage

Adult Dental Coverage

Exclusions and Limitations

Physician Finder

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Blue Saver Bronze

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Benefits & Coverage

Costs for Medical Care

Prescription drug coverage

Access to doctors and hospitals

Hospital services

Maternity

Mental Health

Medical Management Programs

Vision Coverage

Child Dental Coverage

Adult Dental Coverage

Exclusions and Limitations

Physician Finder

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