2018 BlueChoice HMO Standard Bronze $6,000 Plan Details - HealthPocket

BlueChoice HMO Standard Bronze $6,000

$275.22/mo

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Zip Code20011
Applicant11/16/1983 Male
Coverage Start11/17/2018

Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBlueChoice HMO Standard Bronze $6,000
Plan IDhhs-86052DC0400007
Plan Year2018
Insurance ProviderCareFirst BlueCross BlueShield
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$6,000
Out-of-Pocket Maximum$7,350
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$50 Copay
Specialist Visit$75 Copay
Laboratory Outpatient and Professional Services$55 Copay after deductible
X-rays and Diagnostic Imaging$75 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans$500 Copay after deductible
Deductible - Family$12000 per group
Out-of-Pocket Maximum - Family$14700 per group

Prescription drug coverage

Generic Drugs$25 Copay
Preferred Brand Drugs$75 Copay after deductible
Non-Preferred Brand Drugs$100 Copay after deductible
Specialty Drugs$150 Copay after deductible

Access to doctors and hospitals

Provider directory URLhttps://member.carefirst.com/mos/#/fappublic/search/standard?sType=M&planName=BlueChoice%20HMO
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 - Emergency Services only
Does this plan cover services outside the country?Yes - Emergency Services only

Hospital services

Emergency Room Services25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)25.00% Coinsurance after deductible
Inpatient Physician and Surgical Services25.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service25.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity care25.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$50 Copay
Mental/Behavioral Health Inpatient Services25.00% Coinsurance after deductible
Substance use disorder outpatient services$50 Copay
Substance use disorder inpatient services25.00% 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?Included

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsIncluded

Child Dental Coverage

Child Dental Coverage - Routine Dental CareIncluded
Child Dental Coverage - Basic Dental CareIncluded
Child Dental Coverage - OrthodontiaIncluded
Child Dental Coverage - Major Dental CareIncluded

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
Habilitation Services
Durable Medical Equipment
Chiropractic Care
Diabetes Care Management
Abortion for Which Public Funding is Prohibited
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Clinical Trials
Prescription Drugs Other
More Limited BenefitsSkilled Nursing Facility
Home Health Care Services
Outpatient Rehabilitation Services
Hospice Services
Dental Check-Up for Children
More Excluded BenefitsAcupuncture
Bariatric Surgery
Cosmetic Surgery
Hearing Aids
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.
PremiumPlan NameDeductible
from $283
BlueChoice HMO HSA Standard Bronze $6,200
$6,200.00Select
from $320
BluePreferred PPO HSA Standard Bronze $6,200
$6,200.00Select

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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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.