ENGAGE LB650-IN18
$394.74/mo
Apply For This Plan
| Zip Code | 33186 |
| Applicant | 11/15/1983 Male |
| Coverage Start | 11/17/2018 |
Benefits & Coverage
| Insurance Type | ACA (Obamacare) |
| Plan Name | ENGAGE LB650-IN18 |
| Plan ID | hhs-19898FL0220026 |
| Plan Year | 2018 |
| Insurance Provider | AvMed |
| Metal Level | Expanded Bronze |
| Plan Type | HMO |
| Deductible | $7,000 |
| Out-of-Pocket Maximum | $7,000 |
| Plan Highlights |
Costs for Medical Care | |
|---|---|
| Primary Care Visit to Treat an Injury or Illness | No Charge after deductible |
| Specialist Visit | No Charge after deductible |
| Laboratory Outpatient and Professional Services | No Charge after deductible |
| X-rays and Diagnostic Imaging | No Charge after deductible |
| Diagnostic Imaging such as MRIs, CT, and PET scans | No Charge after deductible |
| Deductible - Family | $14000 per group |
| Out-of-Pocket Maximum - Family | $14000 per group |
Prescription drug coverage | |
|---|---|
| Generic Drugs | No Charge after deductible |
| Preferred Brand Drugs | No Charge after deductible |
| Non-Preferred Brand Drugs | No Charge after deductible |
| Specialty Drugs | No Charge after deductible |
Access to doctors and hospitals | |
|---|---|
| Provider directory URL | https://www.avmed.org/web/individuals-families |
| Does this plan have access to a national provider network? | No |
| Is a referral required to see a Specialist? | Yes - All except OB/Gyn, Chiropractor, and Podiatrist for diabetic foot care. |
| Does this plan cover services outside plan service area? | Yes - Urgent/Emergent Only |
| Does this plan cover services outside the country? | Yes - Urgent/Emergent Only |
Hospital services | |
|---|---|
| Emergency Room Services | No Charge after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay) | No Charge after deductible |
| Inpatient Physician and Surgical Services | No Charge after deductible |
| Emergency Transportation or Ambulance Service | No Charge after deductible |
Maternity | |
|---|---|
| Prenatal and Postnatal Care | No Charge after deductible |
| Delivery and all inpatient services for maternity care | No Charge after deductible |
Mental Health | |
|---|---|
| Mental/Behavioral Health Outpatient Services | No Charge after deductible |
| Mental/Behavioral Health Inpatient Services | No Charge after deductible |
| Substance use disorder outpatient services | No Charge after deductible |
| Substance use disorder inpatient services | No Charge 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 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 Routine Foot Care Dental Anesthesia Diabetes Care Management Accidental Dental Allergy Testing Chemotherapy Diabetes Education Dialysis Infusion Therapy Laboratory Outpatient and Professional Services Prosthetic Devices Radiation Reconstructive Surgery Transplant Treatment for Temporomandibular Joint Disorders Well Baby Visits and Care Bone Marrow Transplant Congenital Anomaly, including Cleft Lip/Palate Nutrition/Formulas Osteoporosis |
| More Limited Benefits | Skilled 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 Benefits | Acupuncture Bariatric Surgery Cosmetic Surgery Hearing Aids Infertility Treatment Long-Term/Custodial Nursing Home Care Private-Duty Nursing Weight Loss Programs Abortion for Which Public Funding is Prohibited |
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