Bronze 5550

Plan type:

Details: 
Plan BenefitsIn Network Only
Coinsurance

35%

Deductible (single/family)

$5,550/$11,100

Maximum Out Of Pocket (single/family)

$8,550/$17,100

Primary Care Physician Services

$60

Doctors Care/Blue CareOnDemand

$60

Maternity Care

35% after deductible

Specialist Visit

35% after deductible

Urgent Care

$75

Inpatient Hospital Services

$500 copayment, then 35% after deductible

Outpatient Hospital Services

35% after deductible

Emergency Room

$500 copayment, then 35% after deductible

Ambulance

35% after deductible

Freestanding Ambulatory Surgical Center

$200 per visit

Mental Health and Substance Abuse

Covered the same as medical benefits.

Gynecologist Exam (two exams per benefit year)

$0

Routine Screening Mammogram

$0

Routine Screening Colonoscopy

$0

Prescription Drugs

Tier 1: 35% after deductible retail/35% after deductible mail order;
Tier 2: 35% after deductible retail/35% after deductible mail order;
Tier 3: 35% after deductible retail/35% after deductible mail order;
Tier 4: 35% after deductible retail/35% after deductible mail order

Specialty Pharmaceuticals

Tier 5: 35% after deductible retail/35% after deductible mail order;
Tier 6: 35% after deductible retail/35% after deductible mail order

Durable Medical Equipment

35% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

35% after deductible. 30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

Transplants

A BlueChoice-participating facility must provide services and we will treat covered transplants the same as any other medical condition.

Weight: 
-9