BlueSolutions for HSA Direct 6300/12600 WPDAcu Plan Details for 2021- HealthPocket

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Applicant Info
Applicant
Date of birth
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Gender
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female
Income
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Zip Code	02909 (edit)
Applicant	3/6/1986 Male (edit)

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Insurance Type	ACA (Obamacare)
Plan Name	BlueSolutions for HSA Direct 6300/12600 WPDAcu
Plan ID	hhs-15287RI1150003
Plan Year	2021
Insurance Provider	Blue Cross Blue Shield of Rhode Island
Metal Level	Expanded Bronze
Plan Type	PPO
Deductible	$6,300
Out-of-Pocket Maximum	$7,000
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	10.00% Coinsurance after deductible
Specialist Visit	10.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	10.00% Coinsurance after deductible
X-rays and Diagnostic Imaging	10.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans	10.00% Coinsurance after deductible
Deductible - Family	$12600 per group
Out-of-Pocket Maximum - Family	$14000 per group

Prescription drug coverage
Generic Drugs	$35 Copay after deductible
Preferred Brand Drugs	$60 Copay after deductible
Non-Preferred Brand Drugs	$100 Copay after deductible
Specialty Drugs	$200 Copay after deductible

Access to doctors and hospitals
Provider directory URL	https://www.bcbsri.com/finddoctor
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 - For BlueCard Access call 1-800-810-BLUE (2583) or visit the BlueCard PPO Doctor and Hospital finder web page at www.bcbs.com.
Does this plan cover services outside the country?	No - Coverage for urgent or emergent care only.

Hospital services
Emergency Room Services	10.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	10.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	10.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service	10.00% Coinsurance after deductible

Maternity
Prenatal and Postnatal Care	10.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care	10.00% Coinsurance after deductible

Mental Health
Mental/Behavioral Health Outpatient Services	10.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services	10.00% Coinsurance after deductible
Substance use disorder outpatient services	10.00% Coinsurance after deductible
Substance use disorder inpatient services	10.00% Coinsurance after deductible

Medical Management Programs
Does this plan offer disease managment programs?	Asthma, Diabetes, High Blood Pressure & High Cholesterol
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	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

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

+ See All Coverage Details

Premium	Plan Name	Deductible
from $288	BlueSolutions for HSA Direct 6300/12600 WOPDAB	$6,300.00	Select
from $289	BlueSolutions for HSA Direct 6300/12600 WOPDAcu	$6,300.00	Select
from $290	BlueSolutions for HSA Direct 6300/12600 WPDAB	$6,300.00	Select

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Phone Number
(401) 444-0540
Office Locations
100 Curtis St
Providence, RI 02909

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Date of birth
//
Gender
male
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Income
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BlueSolutions for HSA Direct 6300/12600 WPDAcu

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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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