BlueCross Silver S02E

Individual Health Insurance (Obamacare)

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Benefits & Coverage

Plan Name
BlueCross Silver S02E
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
50% Coinsurance after deductible
Specialist Visit
50% Coinsurance after deductible
Laboratory Outpatient and Professional Services
50% Coinsurance after deductible
X-rays and Diagnostic Imaging
50% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans
50% Coinsurance after deductible
Deductible - Family
$2000
Out-of-Pocket Maximum - Family
$12500

Prescription drug coverage

Generic Drugs
$3 Copay
Preferred Brand Drugs
50% Coinsurance
Non-Preferred Brand Drugs
50% Coinsurance
Specialty Drugs
50% Coinsurance

Access to doctors and hospitals

Provider directory URL
http://www.bcbst.com/tools/findadoctor/
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 - Out of State is BlueCard PPO, In State is Out of Network Benefits
Does this plan cover services outside the country?
Yes - BlueCard Worldwide

Hospital services

Emergency Room Services
50% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
$0 Copay per Day, 50% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Inpatient Physician and Surgical Services
50% Coinsurance after deductible
Emergency Transportation or Ambulance Service
50% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care
50% Coinsurance after deductible
Delivery and all inpatient services for maternity care
50% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services
50% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
50% Coinsurance after deductible
Substance use disorder outpatient services
50% Coinsurance after deductible
Substance use disorder inpatient services
50% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?
Asthma, Heart Disease, Diabetes
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
Not Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental Care
Included
Child Dental Coverage - Basic Dental Care
Included
Child Dental Coverage - Orthodontia
Included
Child Dental Coverage - Major Dental Care
Included

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)
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
Hospice Services
Durable Medical Equipment
Dental Anesthesia
Diabetes Care Management
Inherited Metabolic Disorder - PKU
Accidental Dental
Chemotherapy
Allergy Testing
Dialysis
Diabetes Education
Laboratory Outpatient and Professional Services
Radiation
Nutritional Counseling
Infusion Therapy
Prosthetic Devices
Reconstructive Surgery
Transplant
Well Baby Visits and Care
Treatment for Temporomandibular Joint Disorders
Clinical Trials
Congenital Anomaly, including Cleft Lip/Palate
Off Label Prescription Drugs
More Limited Benefits
Preventive Care/Screening/Immunization
Skilled Nursing Facility
Hearing Aids
Home Health Care Services
Habilitation Services
Outpatient Rehabilitation Services
Dental Check-Up for Children
Chiropractic Care
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded Benefits
Acupuncture
Bariatric Surgery
Cosmetic Surgery
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Routine Foot Care
Non-Emergency Care When Traveling Outside the U.S.
Abortion for Which Public Funding is Prohibited

What To Know

  • This is an ACA (Obamacare) compliant health plan.
  • This plan is eligible for a tax credit subsidy

Physician Directory

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