2018 Blue Cross Premier PPO Bronze Extra Plan Details - HealthPocket

Blue Cross Premier PPO Bronze Extra

$368.93/mo

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Zip Code48228
Applicant8/17/1983 Male
Coverage Start8/18/2018
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBlue Cross Premier PPO Bronze Extra
Plan IDhhs-15560MI1120001
Insurance ProviderBlue Cross Blue Shield of Michigan
Metal LevelExpanded Bronze
Plan TypePPO
Deductible$6,650
Out-of-Pocket Maximum$7,350
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$35 Copay
Specialist Visit$75 Copay
Laboratory Outpatient and Professional Services40.00% Coinsurance after deductible
X-rays and Diagnostic Imaging40.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans40.00% Coinsurance after deductible
Deductible - Family$13300 per group
Out-of-Pocket Maximum - Family$14700 per group

Prescription drug coverage

Generic Drugs$35 Copay
Preferred Brand Drugs35.00% Coinsurance after deductible
Non-Preferred Brand Drugs40.00% Coinsurance after deductible
Specialty Drugs45.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttp://www.bcbsm.com/index/find-a-doctor.html
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 - Accidental injury and emergency only
Does this plan cover services outside the country?Yes - Accidental injury and emergency only

Hospital services

Emergency Room Services40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)40.00% Coinsurance after deductible
Inpatient Physician and Surgical Services40.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service40.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care$35 Copay
Delivery and all inpatient services for maternity care40.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$35 Copay
Mental/Behavioral Health Inpatient Services40.00% Coinsurance after deductible
Substance use disorder outpatient services$35 Copay
Substance use disorder inpatient services40.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
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 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)
Preventive Care/Screening/Immunization
Infertility Treatment
Weight Loss Programs
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
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
Online Visits
More Limited BenefitsSkilled Nursing Facility
Bariatric Surgery
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Nutritional Counseling
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsAcupuncture
Cosmetic Surgery
Hearing Aids
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Dental Check-Up for Children
Routine Foot Care
Abortion for Which Public Funding is Prohibited
PremiumPlan NameDeductible
from $172
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MyPriority HSA Bronze 6650 - Beaumont Health Network
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MyPriority HSA Bronze 6650 - Spectrum Health Partners
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from $180
Molina Marketplace Options Bronze Plan
$6,650.00Select
from $182
MyPriority HSA Bronze 6650 - St. Joseph Mercy Health System Net
$6,650.00Select

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