Silver 2500 with PCP/Rx Copays

Individual Health Insurance (Obamacare)

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Benefits & Coverage

Plan Name
Silver 2500 with PCP/Rx Copays
Plan Year
2016
Insurance Type
Individual Health Insurance (Obamacare)
Metal Level
Silver
Out-of-Pocket Maximum
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness
$25 Copay
Specialist Visit
20% Coinsurance after deductible
Laboratory Outpatient and Professional Services
20% Coinsurance after deductible
X-rays and Diagnostic Imaging
20% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans
20% Coinsurance after deductible
Deductible - Family
$5000 per group

Prescription drug coverage

Generic Drugs
$15 Copay
Preferred Brand Drugs
$40 Copay
Non-Preferred Brand Drugs
$70 Copay
Specialty Drugs
20% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URL
https://secure.arkansasbluecross.com/provider_directory/
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 - Benefit Reduction for medical care
Does this plan cover services outside the country?
Yes - Emergency Care

Hospital services

Emergency Room Services
20% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
20% Coinsurance after deductible
Inpatient Physician and Surgical Services
20% Coinsurance after deductible
Emergency Transportation or Ambulance Service
20% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care
20% Coinsurance after deductible
Delivery and all inpatient services for maternity care
20% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services
$25 Copay
Mental/Behavioral Health Inpatient Services
20% Coinsurance after deductible
Substance use disorder outpatient services
$25 Copay
Substance use disorder inpatient services
20% 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, Weight Loss Programs
Does this plan offer a wellness program?
Included

Vision Coverage

Routine Eye Exam for Children
Included
Eye Glasses for Children
Included
Routine Eye Exam for Adults
Included

Child Dental Coverage

Child Dental Coverage - Routine Dental Care
Not Covered
Child Dental Coverage - Basic Dental Care
Not Covered
Child Dental Coverage - Orthodontia
Not Covered
Child Dental Coverage - Major Dental Care
Not Covered

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)
Hearing Aids
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
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Hospice Services
Chiropractic Care
Routine Foot Care
Applied Behavior Analysis Based Therapies
Cochlear Implants
Dental Anesthesia
Diabetes Care Management
Inherited Metabolic Disorder - PKU
Mental Health Other
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Gastric Electrical Stimulation
Off Label Prescription Drugs
Well Child Care
Preventive Drugs
Craniofacial Surgery
Specialty Drugs Tier 2
More Limited Benefits
Preventive Care/Screening/Immunization
Skilled Nursing Facility
Home Health Care Services
More Excluded Benefits
Acupuncture
Bariatric Surgery
Cosmetic Surgery
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Non-Emergency Care When Traveling Outside the U.S.
Abortion for Which Public Funding is Prohibited

What To Know

  • This is an ACA (Obamacare) compliant health plan.

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