2018 BlueSelect Bronze 1737S Plan Details - HealthPocket

BlueSelect Bronze 1737S

$342.10/mo

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Zip Code33186
Applicant10/15/1983 Male
Coverage Start10/16/2018
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBlueSelect Bronze 1737S
Plan IDhhs-16842FL0120082
Plan Year2018
Insurance ProviderBlue Cross Blue Shield of Florida
Metal LevelExpanded Bronze
Plan TypeEPO
Deductible$6,650
Out-of-Pocket Maximum$7,350
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$35 Copay
Specialist Visit$75 Copay
Laboratory Outpatient and Professional Services40.00% Coinsurance after deductible
X-rays and Diagnostic Imaging40.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans40.00% Coinsurance after deductible
Deductible - Family$13300 per group
Out-of-Pocket Maximum - Family$14700 per group

Prescription drug coverage

Generic Drugs$35 Copay
Preferred Brand Drugs35.00% Coinsurance after deductible
Non-Preferred Brand Drugs40.00% Coinsurance after deductible
Specialty Drugs45.00% 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 Services40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)40.00% Coinsurance after deductible
Inpatient Physician and Surgical Services40.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service40.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care$75 Copay
Delivery and all inpatient services for maternity care40.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$35 Copay
Mental/Behavioral Health Inpatient Services40.00% Coinsurance after deductible
Substance use disorder outpatient services$35 Copay
Substance use disorder inpatient services40.00% Coinsurance 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
PremiumPlan NameDeductible
from $216
Ambetter Essential Care 7 (2018)
$6,500.00Select
from $224
Ambetter Essential Care 1 (2018)
$6,800.00Select
from $225
IND Bronze Standardized HMO
$6,650.00Select
from $227
Ambetter Essential Care 1 (2018) + Vision
$6,800.00Select
from $233
Ambetter Essential Care 1 (2018) + Vision + Adult Dental
$6,800.00Select

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