Blue AdvanceHealth Bronze (4 Free Primary Care In-Person/Virtua Plan Details for 2021- HealthPocket

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	$17100 per group
Out-of-Pocket Maximum - Family	$17100 per group

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

$17100 per group

Out-of-Pocket Maximum - Family

$17100 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

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.azblue.com/individualsandfamilies/find-a-doctor
Does this plan have access to a national provider network?	No
Is a referral required to see a Specialist?	Yes - You must select a network PCP and notify BCBSAZ of your selection. PCP referral required for all Specialists except OB/GYN, Chiropractors, Outpatient Behavioral Health providers, Physical Therapy, Occupational Therapy, Speech Therapy, Cognitive Therapy (PT, OT, ST, CT) and Cardiac and Pulmonary Rehabilitative and Habilitative Services, Pediatric Dental and Vision services, Telehealth and Urgent Care services, Walk-in Clinics, and Emergency services.
Does this plan cover services outside plan service area?	Yes - Emergencies, Urgent Care and Authorized Follow-up Care. Urgent Care and Authorized Follow-up Care covered only through contracted providers.
Does this plan cover services outside the country?	Yes - Emergencies Only. Authorization required for non-emergent services.

Access to doctors and hospitals

Provider directory URL

https://www.azblue.com/individualsandfamilies/find-a-doctor

Does this plan have access to a national provider network?

Is a referral required to see a Specialist?

Yes - You must select a network PCP and notify BCBSAZ of your selection. PCP referral required for all Specialists except OB/GYN, Chiropractors, Outpatient Behavioral Health providers, Physical Therapy, Occupational Therapy, Speech Therapy, Cognitive Therapy (PT, OT, ST, CT) and Cardiac and Pulmonary Rehabilitative and Habilitative Services, Pediatric Dental and Vision services, Telehealth and Urgent Care services, Walk-in Clinics, and Emergency services.

Does this plan cover services outside plan service area?

Yes - Emergencies, Urgent Care and Authorized Follow-up Care. Urgent Care and Authorized Follow-up Care covered only through contracted providers.

Does this plan cover services outside the country?

Yes - Emergencies Only. Authorization required for non-emergent services.

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

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

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

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 a wellness program?	Not Covered

Medical Management Programs

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

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

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

Exclusions and Limitations

More Included Benefits

Other Practitioner Office Visit (Nurse, Physician Assistant)
Bariatric Surgery
Private-Duty Nursing
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
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

More Limited Benefits

Preventive Care/Screening/Immunization
Skilled Nursing Facility
Hearing Aids
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Dental Check-Up for Children
Chiropractic Care
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy

More Excluded Benefits

Acupuncture
Cosmetic Surgery
Infertility Treatment
Weight Loss Programs
Routine Foot Care
Abortion for Which Public Funding is Prohibited
Long-Term/Custodial Nursing Home Care

Premium	Plan Name	Deductible
from $258	Oscar Secure (Free 24/7 Virtual Visits + Free Personal Care Tea	$8,550.00	Select
from $332	Cigna Connect 8550	$8,550.00	Select
from $469	Blue AdvanceHealth Bronze (4 Free Primary Care In-Person/Virtua	$8,550.00	Select

Premium

Plan Name

Deductible

from $258

Oscar Secure (Free 24/7 Virtual Visits + Free Personal Care Tea

$8,550.00

Select

from $332

Cigna Connect 8550

$8,550.00

Select

from $469

Blue AdvanceHealth Bronze (4 Free Primary Care In-Person/Virtua

$8,550.00

Select

Last Name

Location/Distance

Please select the correct zip

Rajesh, Khona

Kita, Patel

William, Shea

Timothy, Graham

Jay, Eldridge

Donald, Runyan

Shawn, Hermenau

Sw Rehab

Nicolas, Santos

Nnabuikem, Anaba

Kailey, Rote

Joseph, Sanchez

Michael, Mccullagh

Zachary, Parkinson

Shanti Anesthesiology, Pllc

Nafisah, Naqvi

Stephanie, Clark

Mina, Tawadrous

Lee, Barnwell

Marjorie, Bacon

Jennifer, Mccumbee

James, Lavin

Kemell Health Llc

Southwestern Palliative Care Associates Plc

View All Details

Rajesh Khona, M.D.

View All Details

Phone Number
(602) 273-6770
Office Locations
2400 S Avenue A
Yuma, AZ 85364

Zip Code	85364 (edit)
Applicant	1/22/1986 Male (edit)

Insurance Type	ACA (Obamacare)
Plan Name	Blue AdvanceHealth Bronze (4 Free Primary Care In-Person/Virtua
Plan ID	hhs-53901AZ1420107
Plan Year	2021
Insurance Provider	Blue Cross Blue Shield of Arizona
Metal Level	Expanded Bronze
Plan Type	HMO
Deductible	$8,550
Out-of-Pocket Maximum	$8,550
Plan Highlights

Zip Code	85364 (edit)
Applicant	1/22/1986 Male (edit)

Blue AdvanceHealth Bronze (4 Free Primary Care In-Person/Virtua

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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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