Blue Advantage Bronze HMO? 204 Plan Details for 2021- HealthPocket

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Applicant Info
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Date of birth
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Zip Code	79936 (edit)
Applicant	3/4/1986 Male (edit)

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Insurance Type	ACA (Obamacare)
Plan Name	Blue Advantage Bronze HMO? 204
Plan ID	hhs-33602TX0460717
Plan Year	2021
Insurance Provider	BlueCross BlueShield of Texas
Metal Level	Expanded Bronze
Plan Type	HMO
Deductible	$6,000
Out-of-Pocket Maximum	$8,550
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	$40 Copay
Specialist Visit	50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	40.00% Coinsurance after deductible
X-rays and Diagnostic Imaging	40.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans	40.00% Coinsurance after deductible
Deductible - Family	$17100 per group
Out-of-Pocket Maximum - Family	$17100 per group

Prescription drug coverage
Generic Drugs	$15 Copay
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://www.bcbstx.com/onlinedirectory/index.htm
Does this plan have access to a national provider network?	No
Is a referral required to see a Specialist?	Yes - Referrals are required for some services. Please check with your Medical Group for details.
Does this plan cover services outside plan service area?	Yes - Coverage outside our service area is available for Emergency and Urgent Care services only.
Does this plan cover services outside the country?	Yes - No coverage for any services, supplies or drugs received by a Member outside of the United States, except for Emergency Care.

Hospital services
Emergency Room Services	$950 Copay with deductible, 50.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Inpatient Hospital Services (e.g., Hospital Stay)	$850 Copay per Stay with deductible, 50.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Inpatient Physician and Surgical Services	50.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service	50.00% Coinsurance after deductible

Maternity
Prenatal and Postnatal Care	$40 Copay
Delivery and all inpatient services for maternity care	$850 Copay with deductible, 50.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.

Mental Health
Mental/Behavioral Health Outpatient Services	50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services	$850 Copay per Stay with deductible, 50.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Substance use disorder outpatient services	50.00% Coinsurance after deductible
Substance use disorder inpatient services	$850 Copay per Stay with deductible, 50.00% 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

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

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 Prosthetic Devices Radiation Reconstructive Surgery Rehabilitative Speech Therapy Transplant Treatment for Temporomandibular Joint Disorders Well Baby Visits and Care Prescription Drugs Other Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited Benefits	Skilled Nursing Facility Hearing Aids Home Health Care Services Outpatient Rehabilitation Services Habilitation Services Chiropractic Care Rehabilitative Occupational and Rehabilitative Physical Therapy
More Excluded Benefits	Acupuncture Bariatric Surgery Cosmetic Surgery Infertility Treatment Long Term Care Private-Duty Nursing Weight Loss Programs Dental Check-Up for Children Routine Foot Care Dental Care - Adult Abortion for Which Public Funding is Prohibited Nutritional Counseling Long-Term/Custodial Nursing Home Care

+ See All Coverage Details

Premium	Plan Name	Deductible
from $324	Oscar Bronze Classic ($3 Prescription List + Free 24/7 Virtual	$6,000.00	Select
from $333	Oscar Bronze Classic PCP Copay ($3 Prescription List + Free 24/	$6,000.00	Select
from $336	Ambetter Balanced Care 201 HSA (2021)	$5,800.00	Select
from $352	Ambetter Balanced Care 201 HSA (2021) + Vision + Adult Dental	$5,800.00	Select
from $437	Oscar Silver Saver 2 ($3 Prescription List + Free 24/7 Virtual	$6,200.00	Select

Last Name

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Marisela, Gomez

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Saranya, Gangupalli

Elena, Paul

Jose, Ruiz

Huma Lodhi, M.D.

Phone Number
(915) 225-3807
Office Locations
11351 James Watt Dr
El Paso, TX 79936

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

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Blue Advantage Bronze HMO? 204

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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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