2018 HMO Blue Basic Deductible Plan Details - HealthPocket

HMO Blue Basic Deductible


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Zip Code02128
Applicant8/21/1983 Male
Coverage Start8/23/2018
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameHMO Blue Basic Deductible
Plan IDhhs-42690MA1290068
Insurance ProviderBlue Cross Blue Shield of Massachusetts
Metal LevelExpanded Bronze
Plan TypeHMO
Out-of-Pocket Maximum$7,000
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$30 Copay after deductible
Specialist Visit$50 Copay after deductible
Laboratory Outpatient and Professional Services$25 Copay after deductible
X-rays and Diagnostic Imaging$25 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans$500 Copay after deductible
Deductible - Family$5000 per group
Out-of-Pocket Maximum - Family$14000 per group

Prescription drug coverage

Generic Drugs$20 Copay
Preferred Brand Drugs$60 Copay after deductible
Non-Preferred Brand Drugs$90 Copay after deductible
Specialty Drugs$60 Copay after deductible

Access to doctors and hospitals

Provider directory URLhttp://www.bluecrossma.com/wps/portal/members/using-my-plan/doctors-hospitals/findadoctor/
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Yes - All professional provider specialists except for OB/GYN and Chiropractor
Does this plan cover services outside plan service area?Yes - Emergency and Urgent Care Services only
Does this plan cover services outside the country?Yes - Emergency and Urgent Care Services only

Hospital services

Emergency Room Services$700 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)$1000 Copay per Stay after deductible
Inpatient Physician and Surgical ServicesNot Applicable
Emergency Transportation or Ambulance ServiceNot Applicable


Prenatal and Postnatal CareNot Applicable
Delivery and all inpatient services for maternity care$1000 Copay after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$30 Copay after deductible
Mental/Behavioral Health Inpatient Services$1000 Copay per Stay after deductible
Substance use disorder outpatient services$30 Copay after deductible
Substance use disorder inpatient services$1000 Copay per Stay after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy
Does this plan offer a wellness program?Included

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsIncluded

Child Dental Coverage

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

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
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
Home Health Care Services
Durable Medical Equipment
Hospice Services
Chiropractic Care
Diabetes Care Management
Abortion for Which Public Funding is Prohibited
Allergy Testing
Diabetes Education
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Reconstructive Surgery
Rehabilitative Speech Therapy
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Bone Marrow Transplants for Treatment of Breast Cancer
Cardiac Rehabilitation
Clinical Trials
Congenital Anomaly, including Cleft Lip/Palate
Contraceptive Services
Early Intervention Services
Hormone Replacement Therapy (HRT)
Human Leukocyte Antigen Testing
Hypodermic Syringes or Needles
Off Label Prescription Drugs
More Limited BenefitsPreventive Care/Screening/Immunization
Skilled Nursing Facility
Hearing Aids
Weight Loss Programs
Outpatient Rehabilitation Services
Habilitation Services
Rehabilitative Occupational and Rehabilitative Physical Therapy
More Excluded BenefitsAcupuncture
Cosmetic Surgery
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Dental Check-Up for Children
Routine Foot Care
Accidental Dental
PremiumPlan NameDeductible
from $446
Standard Bronze
from $503
Choice Mass HMO Copay $2500/$5000 ded. cnt
from $503
Choice Mass HMO Copay $2500/$5000 ded. cal

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