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Zip Code	02128 (edit)
Applicant	2/19/1984 Male (edit)
Coverage Start	2/20/2019 (edit)

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Insurance Type	ACA (Obamacare)
Plan Name	HMO Blue Select $2,000 Deductible with Copayment
Plan ID	hhs-42690MA1390009
Plan Year	2019
Insurance Provider	Blue Cross Blue Shield of Massachusetts
Metal Level	Silver
Plan Type	HMO
Deductible	$2,000
Out-of-Pocket Maximum	$7,500
Personal Score
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	$25 Copay
Specialist Visit	$45 Copay
Laboratory Outpatient and Professional Services	$55 Copay after deductible
X-rays and Diagnostic Imaging	$55 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans	$150 Copay after deductible
Deductible - Family	$4000 per group
Out-of-Pocket Maximum - Family	$15000 per group

Prescription drug coverage
Generic Drugs	$50 Copay
Preferred Brand Drugs	$175 Copay
Non-Preferred Brand Drugs	$250 Copay
Specialty Drugs	$175 Copay

Access to doctors and hospitals
Provider directory URL	http://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 specialists except OB/GYN providers
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	$250 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	$500 Copay per Stay after deductible
Inpatient Physician and Surgical Services	Not Applicable
Emergency Transportation or Ambulance Service	Not Applicable

Maternity
Prenatal and Postnatal Care	Not Applicable
Delivery and all inpatient services for maternity care	$500 Copay after deductible

Mental Health
Mental/Behavioral Health Outpatient Services	$25 Copay
Mental/Behavioral Health Inpatient Services	$500 Copay per Stay after deductible
Substance use disorder outpatient services	$25 Copay
Substance use disorder inpatient services	$500 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 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) 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 Chemotherapy Diabetes Education Dialysis Infusion Therapy Laboratory Outpatient and Professional Services Nutritional Counseling Prosthetic Devices Radiation Reconstructive Surgery Rehabilitative Speech Therapy Transplant 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 Nutrition/Formulas Off Label Prescription Drugs
More Limited Benefits	Preventive Care/Screening/Immunization Skilled Nursing Facility Hearing Aids Weight Loss Programs Outpatient Rehabilitation Services Habilitation Services Rehabilitative Occupational and Rehabilitative Physical Therapy
More Excluded Benefits	Acupuncture Cosmetic Surgery Long-Term/Custodial Nursing Home Care Private-Duty Nursing Dental Check-Up for Children Routine Foot Care Accidental Dental

+ See All Coverage Details

Premium

Plan Name

Deductible

from $302

Standard Silver: Tufts Health Direct Silver 2000 II

$2,000.00

Select

from $367

Standard Low Gold: Tufts Health Direct Gold 2000

$2,000.00

Select

from $457

HMO Blue Select Saver $2,000

$2,000.00

Select

from $475

HMO HSA 2000 with Coinsurance - Flex

$2,000.00

Select

from $495

HMO Blue New England Basic Copayment

$2,000.00

Select

Last Name

Location/Distance

Please select the correct zip

Fantes, Jackie

Chou, Loretta

Silva, Catherine

Williams, Charles

Scarfo, Lisa

Haddad, Heba

Shopland, Victoria

Maclean, Jessica

Nunez, Nairoby

Bird, Julia

Carr, Alison

Trussell, Kelly

D'aurora, Adrianna

East Boston Physical Therapy Center, Inc.

Gonzalez, Marissa

Young, Maureen

Del Rey, Caroline

Llovet, Aliza

Slowe, Erin

Borda Sanchez, Gustavo

View All Details

Jackie Fantes, MD

View All Details

Phone Number
(617) 569-5800
Office Locations
10 Gove St
East Boston, MA 02128

What Is the Silver Plan?
ObamaCare’s Silver Plan is a type of Metal Plan on the Health Insurance Marketplace. Silver Plans qualify for both Tax Credits and Cost Sharing subsidies.Silver Plans have lower out-of-pocket costs than Bronze Plans but higher out- of-pocket costs than both Gold and Platinum Plans. All Silver Plans share the same minimum health benefits, but the way they charge out-of-pocket costs can differ significantly.
How are Silver Plans different than other Obamacare health plans?
The fundamental difference among the new Obamacare health plans is the percentage of covered medical costs paid by the health plan. The Silver Plan pays 70% of covered medical costs for a typical enrollee. Silver Plans are also the only metal plans which offer cost-sharing reduction (CSR) versions to consumers that require financial assistance for out-of-pocket costs.
How much does a Silver Plan cost?
The monthly premium for a Silver Plan depends on the insurer from whom you purchase the plan, the number of people to be insured by the plan, your age, whether you smoke, and the region in which you live. You can use HealthPocket’s comparison tool to compare Silver Plan premiums in your area.
When Can I Enroll in a Silver Plan?
The Open Enrollment period for the 2018 Affordable Care Act health plans begins November 1, 2017 and ends December 15, 2017. See our Open Enrollment article for more information.

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.

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HMO Blue Select $2,000 Deductible with Copayment

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