Insurance Type | ACA (Obamacare) |
Plan Name | Bronze Copay Select 50 |
Plan ID | hhs-77263NJ0210001 |
Plan Year | 2021 |
Insurance Provider | Golden Rule Insurance |
Metal Level | Expanded Bronze |
Plan Type | EPO |
Deductible | $3,000 |
Out-of-Pocket Maximum | $8,550 |
Plan Highlights |
Costs for Medical Care | |
---|---|
Primary Care Visit to Treat an Injury or Illness | 50.00% Coinsurance after deductible |
Specialist Visit | 50.00% Coinsurance after deductible |
Laboratory Outpatient and Professional Services | 50.00% Coinsurance after deductible |
X-rays and Diagnostic Imaging | 50.00% Coinsurance after deductible |
Diagnostic Imaging such as MRIs, CT, and PET scans | 50.00% Coinsurance after deductible |
Deductible - Family | $6000 per group |
Out-of-Pocket Maximum - Family | $17100 per group |
Prescription drug coverage | |
---|---|
Generic Drugs | $15 Copay |
Preferred Brand Drugs | 50.00% Coinsurance after deductible |
Non-Preferred Brand Drugs | 50.00% Coinsurance after deductible |
Specialty Drugs | 50.00% Coinsurance after deductible |
Access to doctors and hospitals | |
---|---|
Provider directory URL | http://www.oxhp.com |
Does this plan have access to a national provider network? | Yes |
Is a referral required to see a Specialist? | Yes - All specialists except for obstetricians and gynecologists. |
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 Services | 50.00% Coinsurance after deductible |
Inpatient Hospital Services (e.g., Hospital Stay) | 50.00% Coinsurance after deductible |
Inpatient Physician and Surgical Services | 50.00% Coinsurance after deductible |
Emergency Transportation or Ambulance Service | 50.00% Coinsurance after deductible |
Maternity | |
---|---|
Prenatal and Postnatal Care | 50.00% Coinsurance after deductible |
Delivery and all inpatient services for maternity care | 50.00% Coinsurance after deductible |
Mental Health | |
---|---|
Mental/Behavioral Health Outpatient Services | 50.00% Coinsurance after deductible |
Mental/Behavioral Health Inpatient Services | 50.00% Coinsurance after deductible |
Substance use disorder outpatient services | 50.00% Coinsurance after deductible |
Substance use disorder inpatient services | 50.00% Coinsurance after deductible |
Medical Management Programs | |
---|---|
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 | Not Covered |
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) Preventive Care/Screening/Immunization Skilled Nursing Facility Bariatric Surgery Infertility Treatment 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 Durable Medical Equipment Hospice Services Diabetes Care Management Inherited Metabolic Disorder - PKU Abortion for Which Public Funding is Prohibited Accidental Dental Allergy Testing Chemotherapy 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 Clinical Trials Prescription Drugs Other Outpatient Facility Fee (e.g., Ambulatory Surgery Center) |
More Limited Benefits | 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 Benefits | Acupuncture Cosmetic Surgery Weight Loss Programs Routine Foot Care Diabetes Education Long-Term/Custodial Nursing Home Care |
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