2018 BlueSelect Bronze 1449 Plan Details - HealthPocket

BlueSelect Bronze 1449

$414.56/mo

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Zip Code33186
Applicant8/20/1983 Male
Coverage Start8/21/2018
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBlueSelect Bronze 1449
Plan IDhhs-16842FL0120068
Insurance ProviderBlue Cross Blue Shield of Florida
Metal LevelExpanded Bronze
Plan TypeEPO
Deductible$6,400
Out-of-Pocket Maximum$6,900
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$35 Copay
Specialist Visit$65 Copay
Laboratory Outpatient and Professional Services$20 Copay
X-rays and Diagnostic Imaging50.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans50.00% Coinsurance after deductible
Deductible - Family$12800 per group
Out-of-Pocket Maximum - Family$13800 per group

Prescription drug coverage

Generic Drugs$24 Copay
Preferred Brand Drugs50.00% Coinsurance after deductible
Non-Preferred Brand Drugs50.00% Coinsurance after deductible
Specialty Drugs50.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttp://myportal.bcbsfl.com/wps/portal/opd
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 - Covered services as outlined in the member contract.
Does this plan cover services outside the country?Yes - Covered services as outlined in the member contract.

Hospital services

Emergency Room Services50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)$100 Copay per Stay after deductible
Inpatient Physician and Surgical Services0.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service50.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care$65 Copay
Delivery and all inpatient services for maternity care$100 Copay after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$65 Copay
Mental/Behavioral Health Inpatient Services$100 Copay per Stay after deductible
Substance use disorder outpatient services$65 Copay
Substance use disorder inpatient services$100 Copay per Stay after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy
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
Durable Medical Equipment
Hospice Services
Routine Foot Care
Dental Anesthesia
Diabetes Care Management
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Bone Marrow Transplant
Congenital Anomaly, including Cleft Lip/Palate
Nutrition/Formulas
Off Label Prescription Drugs
Osteoporosis
More Limited BenefitsSkilled Nursing Facility
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
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
Abortion for Which Public Funding is Prohibited
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from $216
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$6,500.00Select
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Gym Access IND Bronze HMO BC 3841
$6,400.00Select
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Gym Access IND Bronze POS BC 3841
$6,400.00Select
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Health First GYM ACCESS Bronze HMO 100 HSA 1658
$6,350.00Select
from $279
BlueSelect Bronze 1449
$6,400.00Select

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