2018 Best Buy HSA PPO 4500 - Flex Plan Details - HealthPocket

Best Buy HSA PPO 4500 - Flex

$415.88/mo

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Zip Code02128
Applicant8/21/1983 Male
Coverage Start8/22/2018
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBest Buy HSA PPO 4500 - Flex
Plan IDhhs-95878MA0150011
Insurance ProviderHarvard Pilgrim
Metal LevelBronze
Plan TypePPO
Deductible$4,500
Out-of-Pocket Maximum$6,400
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$40 Copay after deductible
Specialist Visit$65 Copay after deductible
Laboratory Outpatient and Professional ServicesNo Charge after deductible
X-rays and Diagnostic Imaging$65 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans$750 Copay after deductible
Deductible - Family$9000 per group
Out-of-Pocket Maximum - Family$12800 per group

Prescription drug coverage

Generic Drugs$5 Copay after deductible
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://www.providerlookuponline.com/Harvardpilgrim/po7/Search.aspx
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 - All covered benefits with the exception of Emergency Care are covered at the Out of Network cost sharing
Does this plan cover services outside the country?Yes - All covered benefits with the exception of Emergency Care are covered at the Out of Network cost sharing.

Hospital services

Emergency Room Services$750 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)$1000 Copay per Stay after deductible
Inpatient Physician and Surgical ServicesNo Charge after deductible
Emergency Transportation or Ambulance Service$250 Copay after deductible

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity care$1000 Copay after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$40 Copay after deductible
Mental/Behavioral Health Inpatient Services$1000 Copay per Stay after deductible
Substance use disorder outpatient services$40 Copay after deductible
Substance use disorder inpatient services$1000 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, 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
Acupuncture
Bariatric Surgery
Infertility Treatment
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
Chiropractic Care
Routine Foot Care
Non-Emergency Care When Traveling Outside the U.S.
Diabetes Care Management
Inherited Metabolic Disorder - PKU
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 Speech Therapy
Transplant
Well Baby Visits and Care
Bone Marrow Transplants for Treatment of Breast Cancer
Cardiac Rehabilitation
Clinical Trials
Congenital Anomaly, including Cleft Lip/Palate
Contraceptive Services
Early Intervention Services
Hormone Replacement Therapy (HRT)
Human Leukocyte Antigen Testing
Hypodermic Syringes or Needles
Nutrition/Formulas
Off Label Prescription Drugs
Childbirth Classes
Fitness Club Reimbursement
Low Protein Foods
Minor Dental Care - Child
Convenience Health Care Clinics
More Limited BenefitsSkilled Nursing Facility
Hearing Aids
Weight Loss Programs
Outpatient Rehabilitation Services
Habilitation Services
Dental Check-Up for Children
Inpatient Rehabilitation Services
Rehabilitative Occupational and Rehabilitative Physical Therapy
Treatment for Temporomandibular Joint Disorders
Wigs
More Excluded BenefitsCosmetic Surgery
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
  • What is a bronze plan?

    Bronze Plan is a type of Metal Plan on the Health Insurance Marketplace. Bronze Plans qualify for Tax Credits and have low premiums. Generally speaking, a Bronze Plan is intended to have the lowest premium of the 4 new categories of health plans under the Affordable Care Act but charge the highest out-of-pocket costs for healthcare services.

  • How are Bronze Plans different than other Obamacare health plans?

    The fundamental difference among the new Obamacare health plans is the percentage of covered medical costs paid by the health plan. The Bronze Plan pays 60% of the covered medical costs among its enrollees while the other Obamacare health plans pay a higher percentage of these costs.

  • How much does a Bronze Plan cost?

    The monthly premium for a Bronze Plan depends on the insurer from whom you purchase the plan, the number of people to be insured by the plan, your age, whether you smoke, and the region in which you live. You can use HealthPocket’s comparison tool to compare Bronze Plan premiums in your area. Another important factor to remember is Advanced Premium Tax Credits which can subsidize bronze plan premiums if an individual meets eligibility criteria.

  • When Can I Enroll in a Bronze Plan?

    The annual enrollment period for the 2018 plan year will begin on November 1, 2017 and continue through December 15, 2017.

    In 2015 there had been a Special Enrollment Period for many facing the uninsured penalty on their 2014 tax return. There is no guarantee that a similar Special Enrollment Period will be granted in 2017. See our Open Enrollment article for more information.

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