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Zip Code	04401 (edit)
Applicant	2/18/1984 Male (edit)
Coverage Start	2/19/2019 (edit)

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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
Personal Score
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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Premium

Plan Name

Deductible

from $309

Anthem Bronze X HMO 5000 for HSA

$5,000.00

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from $335

Anthem Bronze X HMO 5000 Online Plus

$5,000.00

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from $342

Anthem Bronze X HMO 5000 for HSA

$5,000.00

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from $343

Anthem Bronze HMO 5000 for HSA

$5,000.00

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from $344

Maines Choice HMO HSA Bronze 5000

$5,000.00

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Last Name

Location/Distance

Please select the correct zip

Bruno, Edwin

Mcguire, D

Castonguay, Bernard

Clark, Peggy

Phillips, Lewis

Macduffie, Heather

Olivos, Guillermo

Dahl, William

Sunbury Walk In Care

Guerrette, Chandler

Madore, Nicole

Jamison, Tyler

Delusso, Joan

Winslow, Kelsey

Lifeworks Of Maine Llc

Makura, Zvorufura

Smith, Haley

Pierce, Jolene

Arno, Lindsey

Cyr, Katelyn

Todd, Katie

Clifford, Julie

Soucy, Matthew

Andrews, Emily

Edwin Bruno, D.P.M.

Phone Number
(207) 942-3988
Office Locations
277 State St
Bangor, ME 04401

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Anthem Bronze POS 5000 for HSA

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