BlueChoice HMO Value Bronze $6,100 Plan Details for 2021- HealthPocket

BlueChoice HMO Value Bronze $6,100

$234.31/mo

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Zip Code21215
Applicant7/3/1987 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBlueChoice HMO Value Bronze $6,100
Plan IDhhs-28137MD0370016
Plan Year2021
Insurance ProviderCareFirst BlueCross BlueShield
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$6,100
Out-of-Pocket Maximum$8,300
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$40 Copay
Specialist Visit$50 Copay after deductible
Laboratory Outpatient and Professional Services$25 Copay after deductible
X-rays and Diagnostic Imaging$55 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans$250 Copay after deductible
Deductible - Family$12200 per group
Out-of-Pocket Maximum - Family$16600 per group

Prescription drug coverage

Generic Drugs$20 Copay after deductible
Preferred Brand Drugs$50 Copay after deductible
Non-Preferred Brand Drugs$70 Copay after deductible
Specialty Drugs$150 Copay after deductible

Access to doctors and hospitals

Provider directory URLhttps://member.carefirst.com/mos/#/fappublic/search/standard?sType=M&planName=BlueChoice%20HMO
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?No -
Does this plan cover services outside plan service area?Yes - Emergency Services Only
Does this plan cover services outside the country?Yes - Emergency Services Only

Hospital services

Emergency Room Services40% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)40% Coinsurance after deductible
Inpatient Physician and Surgical Services$50 Copay after deductible
Emergency Transportation or Ambulance Service$50 Copay after deductible

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity care40% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$40 Copay
Mental/Behavioral Health Inpatient Services40% Coinsurance after deductible
Substance use disorder outpatient services$40 Copay
Substance use disorder inpatient services40% Coinsurance after deductible

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?Covered

Vision Coverage

Routine Eye Exam for ChildrenCovered
Eye Glasses for ChildrenCovered
Routine Eye Exam for AdultsCovered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareCovered
Child Dental Coverage - Basic Dental CareCovered
Child Dental Coverage - OrthodontiaCovered
Child Dental Coverage - Major Dental CareCovered

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
Acupuncture
Bariatric Surgery
Infertility Treatment
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
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
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsSkilled Nursing Facility
Hearing Aids
Outpatient Rehabilitation Services
Habilitation Services
Dental Check-Up for Children
Chiropractic Care
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsCosmetic Surgery
Private-Duty Nursing
Weight Loss Programs
Routine Foot Care
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $237Balance Bronze Saver (HSA)$5,900.00Select
from $241BlueChoice HMO HSA Bronze $6,150$6,150.00Select
from $339Balance Silver 3 Free Visits$6,000.00Select
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  • Phone Number
    (410) 601-5209
  • Office Locations
    2401 W Belvedere Ave
    Baltimore, MD 21215
2401 W Belvedere Ave Baltimore MD, 21215

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HealthPocket.com is a free information source. 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. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. While on our site, if you click on a plan or link, you may be directed to one of our partners who offers health insurance products. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.