BlueSolutions for HSA Direct 2600/5200 WOPD

Individual Health Insurance (Obamacare)

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Benefits & Coverage

Plan Name
BlueSolutions for HSA Direct 2600/5200 WOPD
Plan Year
2015
Insurance Type
Individual Health Insurance (Obamacare)
Metal Level
Silver
Out-of-Pocket Maximum
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness
10% Coinsurance after deductible
Specialist Visit
10% Coinsurance after deductible
Laboratory Outpatient and Professional Services
10% Coinsurance after deductible
X-rays and Diagnostic Imaging
10% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans
10% Coinsurance after deductible
Deductible - Family
$5200
Out-of-Pocket Maximum - Family
$8000

Prescription drug coverage

Generic Drugs
$12 Copay after deductible
Preferred Brand Drugs
$35 Copay after deductible
Non-Preferred Brand Drugs
$60 Copay after deductible
Specialty Drugs
$100 Copay after deductible

Access to doctors and hospitals

Provider directory URL
http://findadoctor.bcbsri.com/
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 - For BlueCard Access call 1-800-810-BLUE (2583) or visit the BlueCard PPO Doctor and Hospital finder web page at www.bcbs.com.
Does this plan cover services outside the country?
Yes - For BlueCard Access call 1-800-810-BLUE (2583) or visit the BlueCard PPO Doctor and Hospital finder web page at www.bcbs.com.

Hospital services

Emergency Room Services
10% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
$0 Copay per Day, 10% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Inpatient Physician and Surgical Services
10% Coinsurance after deductible
Emergency Transportation or Ambulance Service
10% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care
10% Coinsurance after deductible
Delivery and all inpatient services for maternity care
10% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services
10% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
10% Coinsurance after deductible
Substance use disorder outpatient services
10% Coinsurance after deductible
Substance use disorder inpatient services
10% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?
Asthma, Heart Disease, Depression, High Blood Pressure & High Cholesterol
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
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)
Preventive Care/Screening/Immunization
Skilled Nursing Facility
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
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Hospice Services
Routine Foot Care
Non-Emergency Care When Traveling Outside the U.S.
Diabetes Care Management
Inherited Metabolic Disorder - PKU
Abortion for Which Public Funding is Prohibited
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Radiation
Reconstructive Surgery
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Well Baby Visits and Care
Clinical Trials
Early Intervention Services
Off Label Prescription Drugs
Transplant Surgery - Donor Charges
More Limited Benefits
Hearing Aids
Infertility Treatment
Chiropractic Care
Prosthetic Devices
Wigs
More Excluded Benefits
Acupuncture
Cosmetic Surgery
Long-Term/Custodial Nursing Home Care
Weight Loss Programs
Dental Check-Up for Children
Treatment for Temporomandibular Joint Disorders

What To Know

  • This is an ACA (Obamacare) compliant health plan.

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