Direct Care Bronze Deductible 5000 Low Plan Details for 2021- HealthPocket

Direct Care Bronze Deductible 5000 Low

$408.07/mo

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Zip Code02128
Applicant9/22/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameDirect Care Bronze Deductible 5000 Low
Plan IDhhs-88806MA0010162
Plan Year2021
Insurance ProviderFallon Community Health Plan
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$5,000
Out-of-Pocket Maximum$8,550
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$60 Copay after deductible
Specialist Visit$90 Copay after deductible
Laboratory Outpatient and Professional Services$200 Copay after deductible
X-rays and Diagnostic Imaging$200 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans$1200 Copay after deductible
Deductible - Family$10000 per group
Out-of-Pocket Maximum - Family$17100 per group

Prescription drug coverage

Generic Drugs$45 Copay
Preferred Brand Drugs$100 Copay
Non-Preferred Brand Drugs$250 Copay
Specialty Drugs$250 Copay

Access to doctors and hospitals

Provider directory URLhttp://www.fallonhealth.org/employers/general-plan-information/networks-service-area.aspx
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Yes - Allergist and Immunologist, Anesthesiologist, Cardiologist, Dermatologist, Doctor of Osteopathic Medicine, Endocrinologist, Gastroenterologists, Hematologists, Infection Diseases, Neonatologists, Neurologists, Nephrologists, Oncologists, Ophthalmologists, Orthopedic Surgeons, Otolaryngologists, Podiatrists, Pulmonologists, Rheumatologists, General Surgeons, Thoracic Surgeons, Vascular Surgeons, Urologists
Does this plan cover services outside plan service area?Not Covered
Does this plan cover services outside the country?Yes - Emergency Only

Hospital services

Emergency Room Services$1200 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)$1200 Copay per Stay after deductible
Inpatient Physician and Surgical ServicesNot Applicable
Emergency Transportation or Ambulance ServiceNot Applicable

Maternity

Prenatal and Postnatal Care$60 Copay after deductible
Delivery and all inpatient services for maternity care$1200 Copay after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$60 Copay after deductible
Mental/Behavioral Health Inpatient ServicesNot Applicable
Substance use disorder outpatient services$60 Copay after deductible
Substance use disorder inpatient servicesNot Applicable

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, Heart Disease
Does this plan offer a wellness program?Included

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsIncluded

Child Dental Coverage

Child Dental Coverage - Routine Dental CareIncluded
Child Dental Coverage - Basic Dental CareIncluded
Child Dental Coverage - OrthodontiaIncluded
Child Dental Coverage - Major Dental CareIncluded

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)
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
Chiropractic Care
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
Rehabilitative Speech Therapy
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsPreventive Care/Screening/Immunization
Skilled Nursing Facility
Hearing Aids
Weight Loss Programs
Outpatient Rehabilitation Services
Habilitation Services
Dental Check-Up for Children
Rehabilitative Occupational and Rehabilitative Physical Therapy
More Excluded BenefitsAcupuncture
Cosmetic Surgery
Private-Duty Nursing
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $372Select Advantage HMO 5000$5,000.00Select
from $413PPO HSA 5000 - Flex$5,000.00Select
from $464Advantage HMO 5000$5,000.00Select
from $474Select Care Bronze Deductible 5000 Low$5,000.00Select
from $512Advantage PPO Saver 5000$5,000.00Select
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Jackie Fantes, MD
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  • Phone Number
    (617) 569-5800
  • Office Locations
    10 Gove St
    East Boston, MA 02128
10 Gove St East Boston MA, 02128

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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.