Anthem Bronze POS 5000 for HSA
$422.92/mo
Benefits & Coverage
| Insurance Type | ACA (Obamacare) |
| Plan Name | Anthem Bronze POS 5000 for HSA |
| Plan ID | hhs-48396ME0800017 |
| Plan Year | 2019 |
| Insurance Provider | Anthem BCBS |
| Metal Level | Expanded Bronze |
| Plan Type | POS |
| Deductible | $5,000 |
| Out-of-Pocket Maximum | $6,700 |
| Plan Highlights |
Costs for Medical Care | |
|---|---|
| Primary Care Visit to Treat an Injury or Illness | 35.00% Coinsurance after deductible |
| Specialist Visit | 35.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | 35.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging | 35.00% Coinsurance after deductible |
| Diagnostic Imaging such as MRIs, CT, and PET scans | 35.00% Coinsurance after deductible |
| Deductible - Family | $10000 per group |
| Out-of-Pocket Maximum - Family | $13400 per group |
Prescription drug coverage | |
|---|---|
| Generic Drugs | 35.00% Coinsurance after deductible |
| Preferred Brand Drugs | 35.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs | 40.00% Coinsurance after deductible |
| Specialty Drugs | 40.00% Coinsurance after deductible |
Access to doctors and hospitals | |
|---|---|
| Provider directory URL | https://www.anthem.com/health-insurance/provider-directory/searchcriteria?brand=abcbs |
| 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? | No - TRAD/PAR network |
| Does this plan cover services outside the country? | No - Urgent/Emergency Coverage Only |
Hospital services | |
|---|---|
| Emergency Room Services | $250 Copay after deductible, 35.00% Coinsurance after deductible. See plan brochure for when Copay is applicable. |
| Inpatient Hospital Services (e.g., Hospital Stay) | 35.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 35.00% Coinsurance after deductible |
| Emergency Transportation or Ambulance Service | 35.00% Coinsurance after deductible |
Maternity | |
|---|---|
| Prenatal and Postnatal Care | 35.00% Coinsurance after deductible |
| Delivery and all inpatient services for maternity care | 35.00% Coinsurance after deductible |
Mental Health | |
|---|---|
| Mental/Behavioral Health Outpatient Services | 35.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services | 35.00% Coinsurance after deductible |
| Substance use disorder outpatient services | 35.00% Coinsurance after deductible |
| Substance use disorder inpatient services | 35.00% 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 |
| 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 Bariatric Surgery 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 Home Health Care Services Durable Medical Equipment Hospice Services Dental Check-Up for Children 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 |
| More Limited Benefits | Skilled Nursing Facility Hearing Aids Outpatient Rehabilitation Services Habilitation Services Chiropractic Care Rehabilitative Occupational and Rehabilitative Physical Therapy Rehabilitative Speech Therapy |
| More Excluded Benefits | Acupuncture Cosmetic Surgery Infertility Treatment Long-Term/Custodial Nursing Home Care Private-Duty Nursing Weight Loss Programs Routine Foot Care Abortion for Which Public Funding is Prohibited Treatment for Temporomandibular Joint Disorders |
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