2018 Hometown North Bronze 5500 Plan Details - HealthPocket

Hometown North Bronze 5500

$301.70/mo

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Zip Code83709
Applicant10/22/1983 Male
Coverage Start10/23/2018
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameHometown North Bronze 5500
Plan IDhhs-61589ID2360118
Plan Year2018
Insurance ProviderBlue Cross of Idaho
Metal LevelExpanded Bronze
Plan TypePOS
Deductible$5,500
Out-of-Pocket Maximum$7,350
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$40 Copay
Specialist Visit$80 Copay
Laboratory Outpatient and Professional Services35.00% Coinsurance after deductible
X-rays and Diagnostic Imaging35.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans$500 Copay, 35.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Deductible - Family$11000 per group
Out-of-Pocket Maximum - Family$14700 per group

Prescription drug coverage

Generic Drugs$10 Copay
Preferred Brand Drugs$30 Copay after deductible
Non-Preferred Brand Drugs$50 Copay after deductible
Specialty Drugs50.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://www.bcidaho.com/BCI_V2/prov_directory/prov_dir_criteria.aspx
Does this plan have access to a national provider network?Yes
Is a referral required to see a Specialist?Yes - Allergy/Immunology, Audiologist,Cardiology, Cardiothoracic Surgery, Colorectal Surgery, Dermatology, Endocrinology, ENT/Otolaryngology, Gastroenterology, General Surgery, Hand Surgery, Hepatologist, Infectious Disease, Nephrology, Neurology, Neurosurgery, Oncology/Hematology, Oral Surgery, Ophthalmology, Orthopedics, Pain Management, Perinatologist, Plastic Surgery, Podiatry, Proctology, Psychiatry, Pulmonology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery
Does this plan cover services outside plan service area?Yes - In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services.
Does this plan cover services outside the country?Yes - The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.

Hospital services

Emergency Room Services$350 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)35.00% Coinsurance after deductible
Inpatient Physician and Surgical Services35.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service35.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care35.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care35.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$40 Copay
Mental/Behavioral Health Inpatient Services35.00% Coinsurance after deductible
Substance use disorder outpatient services$40 Copay
Substance use disorder inpatient services35.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, Heart Disease
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
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
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Well Baby Visits and Care
More Limited BenefitsSkilled Nursing Facility
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Nutritional Counseling
More Excluded BenefitsAcupuncture
Bariatric Surgery
Cosmetic Surgery
Hearing Aids
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Abortion for Which Public Funding is Prohibited
Treatment for Temporomandibular Joint Disorders
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