Personal Choice PPO Bronze Plan Details for 2021- HealthPocket

Personal Choice PPO Bronze

$393.95/mo

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Zip Code19120
Applicant3/7/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NamePersonal Choice PPO Bronze
Plan IDhhs-31609PA0190004
Plan Year2021
Insurance ProviderIndependence Blue Cross
Metal LevelExpanded Bronze
Plan TypePPO
Deductible$6,000
Out-of-Pocket Maximum$8,150
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$50 Copay
Specialist Visit50.00% Coinsurance after deductible
Laboratory Outpatient and Professional ServicesNo Charge after deductible
X-rays and Diagnostic Imaging50.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans50.00% Coinsurance after deductible
Deductible - Family$12000 per group
Out-of-Pocket Maximum - Family$16300 per group

Prescription drug coverage

Generic Drugs$25 Copay
Preferred Brand Drugs50.00% Coinsurance after deductible
Non-Preferred Brand Drugs50.00% Coinsurance after deductible
Specialty Drugs50.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttp://www.ibx.com/providerfinder
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 - Coverage is provided for benefits received anywhere in the U.S.
Does this plan cover services outside the country?Yes - Coverage is provided for benefits received while outside of the U.S.

Hospital services

Emergency Room Services50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)25.00% Coinsurance after deductible
Inpatient Physician and Surgical Services50.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service50.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care50.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care25.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services25.00% Coinsurance after deductible
Substance use disorder outpatient services50.00% Coinsurance after deductible
Substance use disorder inpatient services25.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, 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 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)
Preventive Care/Screening/Immunization
Infertility Treatment
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Durable Medical Equipment
Hospice Services
Dental Anesthesia
Diabetes Care Management
Inherited Metabolic Disorder - PKU
Abortion for Which Public Funding is Prohibited
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Well Baby Visits and Care
Telemedicine
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsSkilled Nursing Facility
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Dental Check-Up for Children
Chiropractic Care
Nutritional Counseling
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsAcupuncture
Bariatric Surgery
Cosmetic Surgery
Hearing Aids
Long Term Care
Private-Duty Nursing
Weight Loss Programs
Routine Foot Care
Dental Care - Adult
Treatment for Temporomandibular Joint Disorders
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $319Ambetter Balanced Care 201 HSA (2021)$5,800.00Select
from $330Oscar Bronze Classic ($3 Prescription List + Free 24/7 Virtual$6,000.00Select
from $337Oscar Bronze Classic PCP Copay ($3 Prescription List + Free 24/$6,000.00Select
from $338Ambetter Balanced Care 201 HSA (2021) + Vision + Adult Dental$5,800.00Select
from $368Oscar Silver Classic Next Off-Ex$6,000.00Select
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  • Phone Number
    (215) 324-2180
  • Office Locations
    448 E Wyoming Ave
    Philadelphia, PA 19120
448 E Wyoming Ave Philadelphia PA, 19120

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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.