BridgeSpan Standard Bronze Plan EPO RealValue Plan Details for 2021- HealthPocket

BridgeSpan Standard Bronze Plan EPO RealValue

$354.77/mo

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Zip Code97229
Applicant6/12/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBridgeSpan Standard Bronze Plan EPO RealValue
Plan IDhhs-63474OR0600009
Plan Year2021
Insurance ProviderBridgespan
Metal LevelExpanded Bronze
Plan TypeEPO
Deductible$8,550
Out-of-Pocket Maximum$8,550
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$50 Copay
Specialist Visit$100 Copay
Laboratory Outpatient and Professional ServicesNo Charge after deductible
X-rays and Diagnostic ImagingNo Charge after deductible
Diagnostic Imaging such as MRIs, CT, and PET scansNo 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 DrugsNo Charge after deductible
Non-Preferred Brand DrugsNo Charge after deductible
Specialty DrugsNo Charge after deductible

Access to doctors and hospitals

Provider directory URLhttp://www.bridgespanhealth.com
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?Not Covered
Does this plan cover services outside the country?Not Covered

Hospital services

Emergency Room ServicesNo Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)No Charge after deductible
Inpatient Physician and Surgical ServicesNo Charge after deductible
Emergency Transportation or Ambulance ServiceNo Charge after deductible

Maternity

Prenatal and Postnatal CareNo Charge after deductible
Delivery and all inpatient services for maternity careNo Charge after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$50 Copay
Mental/Behavioral Health Inpatient ServicesNo Charge after deductible
Substance use disorder outpatient services$50 Copay
Substance use disorder inpatient servicesNo Charge after deductible

Medical Management Programs

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

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareNot Covered
Child Dental Coverage - Basic Dental CareNot Covered
Child Dental Coverage - OrthodontiaNot Covered
Child Dental Coverage - Major Dental CareNot Covered

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Cosmetic Surgery
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Home Health Care Services
Durable Medical Equipment
Hospice Services
Routine Foot Care
Abortion for Which Public Funding is Prohibited
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
Telehealth
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Tier 1 - Zero Cost-Share Preventive Drugs
Tier 2 - Preferred Generic Drugs
Tier 3 - Non-Preferred Generic Drugs
Tier 4 - Preferred Brand Drugs
Tier 5 - Non-Preferred Brand Drugs
Tier 6 - Preferred Specialty Drugs
Tier 7 - Non-Preferred Specialty Drugs
More Limited BenefitsSkilled Nursing Facility
Outpatient Rehabilitation Services
Habilitation Services
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsAcupuncture
Bariatric Surgery
Infertility Treatment
Long Term Care
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Chiropractic Care
Dental Care - Adult
Treatment for Temporomandibular Joint Disorders
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $226Navigator Catastrophic$8,550.00Select
from $257SmartChoice Catastrophic$8,550.00Select
from $299KP OR Bronze 8550/75$8,550.00Select
from $306KP Oregon Standard Bronze Plan$8,550.00Select
from $315Regence Standard Bronze Plan EPO Legacy LHP$8,550.00Select
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  • Phone Number
    (503) 629-0237
  • Office Locations
    14223 Nw Spruceridge Ln
    Portland, OR 97229
14223 Nw Spruceridge Ln Portland OR, 97229

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.