2018 EverydayHealth HMO 6500 - Neighborhood Network Plan Details - HealthPocket

EverydayHealth HMO 6500 - Neighborhood Network

$488.98/mo

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Zip Code85364
Applicant10/18/1983 Male
Coverage Start10/20/2018
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameEverydayHealth HMO 6500 - Neighborhood Network
Plan IDhhs-53901AZ1420018
Plan Year2018
Insurance ProviderBlue Cross Blue Shield of Arizona
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$6,500
Out-of-Pocket Maximum$7,350
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$30 Copay
Specialist Visit$100 Copay
Laboratory Outpatient and Professional Services10.00% Coinsurance after deductible
X-rays and Diagnostic Imaging10.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans10.00% Coinsurance after deductible
Deductible - Family$13000 per group
Out-of-Pocket Maximum - Family$14700 per group

Prescription drug coverage

Generic Drugs$35 Copay
Preferred Brand Drugs$100 Copay after deductible
Non-Preferred Brand Drugs40.00% Coinsurance after deductible
Specialty Drugs50.00% Coinsurance

Access to doctors and hospitals

Provider directory URLhttps://www.azblue.com/individualsandfamilies/find-a-doctor
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Yes - You must select a network PCP and notify BCBSAZ of your selection. PCP referral required for all Specialists except OB/GYN, Chiropractors, Outpatient Behavioral Health providers, Urgent Care services and Emergency services.
Does this plan cover services outside plan service area?Yes - Emergencies and Authorized Follow-up Care
Does this plan cover services outside the country?Yes - Emergencies Only

Hospital services

Emergency Room Services10.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)10.00% Coinsurance after deductible
Inpatient Physician and Surgical Services10.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service10.00% Coinsurance

Maternity

Prenatal and Postnatal Care$100 Copay
Delivery and all inpatient services for maternity care10.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$100 Copay
Mental/Behavioral Health Inpatient Services10.00% Coinsurance after deductible
Substance use disorder outpatient services$100 Copay
Substance use disorder inpatient services10.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes
Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareIncluded
Child Dental Coverage - Basic Dental CareIncluded
Child Dental Coverage - OrthodontiaIncluded
Child Dental Coverage - Major Dental CareIncluded

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Bariatric Surgery
Private-Duty Nursing
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
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
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
More Limited BenefitsPreventive Care/Screening/Immunization
Skilled Nursing Facility
Hearing Aids
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Dental Check-Up for Children
Chiropractic Care
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsAcupuncture
Cosmetic Surgery
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Weight Loss Programs
Routine Foot Care
Abortion for Which Public Funding is Prohibited
PremiumPlan NameDeductible
from $317
Ambetter Essential Care 2 HSA (2018)
$6,550.00Select
from $345
Ambetter Essential Care 2 HSA (2018)
$6,550.00Select
from $362
EverydayHealth HMO 6500 - Neighborhood Network
$6,500.00Select
from $399
Portfolio HSA HMO 6650 - Neighborhood Network
$6,650.00Select
from $417
Portfolio HSA HMO 6650 - Neighborhood Network
$6,650.00Select

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