Blue Advantage Bronze PPO? 203 Plan Details for 2021- HealthPocket

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	40.00% Coinsurance after deductible
Specialist Visit	40.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	30.00% Coinsurance after deductible
X-rays and Diagnostic Imaging	30.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans	30.00% Coinsurance after deductible
Deductible - Family	$13300 per group
Out-of-Pocket Maximum - Family	$13800 per group

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness

40.00% Coinsurance after deductible

Specialist Visit

40.00% Coinsurance after deductible

Laboratory Outpatient and Professional Services

30.00% Coinsurance after deductible

X-rays and Diagnostic Imaging

30.00% Coinsurance after deductible

Diagnostic Imaging such as MRIs, CT, and PET scans

30.00% Coinsurance after deductible

Deductible - Family

$13300 per group

Out-of-Pocket Maximum - Family

$13800 per group

Prescription drug coverage
Generic Drugs	20.00% Coinsurance after deductible
Preferred Brand Drugs	30.00% Coinsurance after deductible
Non-Preferred Brand Drugs	35.00% Coinsurance after deductible
Specialty Drugs	45.00% Coinsurance after deductible

Prescription drug coverage

Generic Drugs

20.00% Coinsurance after deductible

Preferred Brand Drugs

30.00% Coinsurance after deductible

Non-Preferred Brand Drugs

35.00% Coinsurance after deductible

Specialty Drugs

45.00% Coinsurance after deductible

Access to doctors and hospitals
Provider directory URL	http://public.hcsc.net/providerfinder/home.do?corpEntCd=OK8
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 - When accessing care outside our service area, you will obtain care from healthcare Providers that have a contractual agreement (i.e., are Participating Providers) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (Host Blue). In some instances, you may obtain care from Non-Participating Providers.
Does this plan cover services outside the country?	Yes - This plan does not cover any services and/or supplies provided to a member outside of the United States, if the member traveled to the location for the purposes of receiving medical services, supplies, or drugs.

Access to doctors and hospitals

Provider directory URL

http://public.hcsc.net/providerfinder/home.do?corpEntCd=OK8

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 - When accessing care outside our service area, you will obtain care from healthcare Providers that have a contractual agreement (i.e., are Participating Providers) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (Host Blue). In some instances, you may obtain care from Non-Participating Providers.

Does this plan cover services outside the country?

Yes - This plan does not cover any services and/or supplies provided to a member outside of the United States, if the member traveled to the location for the purposes of receiving medical services, supplies, or drugs.

Hospital services
Emergency Room Services	$950 Copay with deductible, 40.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Inpatient Hospital Services (e.g., Hospital Stay)	$400 Copay per Stay with deductible, 40.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Inpatient Physician and Surgical Services	40.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service	40.00% Coinsurance after deductible

Hospital services

Emergency Room Services

$950 Copay with deductible, 40.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.

Inpatient Hospital Services (e.g., Hospital Stay)

$400 Copay per Stay with deductible, 40.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.

Inpatient Physician and Surgical Services

40.00% Coinsurance after deductible

Emergency Transportation or Ambulance Service

40.00% Coinsurance after deductible

Maternity
Prenatal and Postnatal Care	40.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care	$400 Copay with deductible, 40.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.

Maternity

Prenatal and Postnatal Care

40.00% Coinsurance after deductible

Delivery and all inpatient services for maternity care

$400 Copay with deductible, 40.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.

Mental Health
Mental/Behavioral Health Outpatient Services	40.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services	$400 Copay per Stay with deductible, 40.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Substance use disorder outpatient services	40.00% Coinsurance after deductible
Substance use disorder inpatient services	$400 Copay per Stay with deductible, 40.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.

Mental Health

Mental/Behavioral Health Outpatient Services

40.00% Coinsurance after deductible

Mental/Behavioral Health Inpatient Services

$400 Copay per Stay with deductible, 40.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.

Substance use disorder outpatient services

40.00% Coinsurance after deductible

Substance use disorder inpatient services

$400 Copay per Stay with deductible, 40.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.

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

Medical Management Programs

Does this plan offer disease managment programs?

Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

Does this plan offer a wellness program?

Not Covered

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

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	Not Covered
Child Dental Coverage - Basic Dental Care	Not Covered
Child Dental Coverage - Orthodontia	Not Covered
Child Dental Coverage - Major Dental Care	Not Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental Care

Not Covered

Child Dental Coverage - Basic Dental Care

Not Covered

Child Dental Coverage - Orthodontia

Not Covered

Child Dental Coverage - Major Dental Care

Not Covered

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

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

Exclusions and Limitations

More Included Benefits

Other Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Imaging (CT/PET Scans, MRIs)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Durable Medical Equipment
Hospice Services
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Well Baby Visits and Care
Prescription Drugs Other
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

More Limited Benefits

Skilled Nursing Facility
Hearing Aids
Private-Duty Nursing
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy

More Excluded Benefits

Acupuncture
Bariatric Surgery
Cosmetic Surgery
Infertility Treatment
Long Term Care
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Dental Care - Adult
Abortion for Which Public Funding is Prohibited
Treatment for Temporomandibular Joint Disorders
Long-Term/Custodial Nursing Home Care

Premium	Plan Name	Deductible
from $492	UHC Silver-X Value+ ($3 Rx + Unlimited Free Primary Care & Virtual Visits)	$4,500.00	Select

Premium

Plan Name

Deductible

from $492

UHC Silver-X Value+ ($3 Rx + Unlimited Free Primary Care & Virtual Visits)

$4,500.00

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Last Name

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Phone Number
(405) 794-6691
Office Locations
3001 S Telephone Rd
Moore, OK 73160

Zip Code	73160 (edit)
Applicant	6/30/1987 Male (edit)

Insurance Type	ACA (Obamacare)
Plan Name	Blue Advantage Bronze PPO? 203
Plan ID	hhs-87571OK0350084
Plan Year	2021
Insurance Provider	Blue Cross Blue Shield of Oklahoma
Metal Level	Expanded Bronze
Plan Type	PPO
Deductible	$4,500
Out-of-Pocket Maximum	$6,900
Plan Highlights

Zip Code	73160 (edit)
Applicant	6/30/1987 Male (edit)

Blue Advantage Bronze PPO? 203

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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

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Blue Advantage Bronze PPO? 203

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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

Similar Plans

Physician Finder

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Apply For This Plan

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