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 |
Costs for Medical Care | |
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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 | |
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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 | |
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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 | |
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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 | |
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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 | |
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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 | |
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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 | |
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Routine Eye Exam for Children | Included |
Eye Glasses for Children | Included |
Routine Eye Exam for Adults | Not Covered |
Child Dental Coverage | |
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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 |
Exclusions and Limitations | |
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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 |
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