Bronze 6500

Plan type:

Details: 
Plan BenefitsIn Network Only
Coinsurance

20%

Deductible (single/family)

$6,500/$13,000

Maximum Out Of Pocket (single/family)

$8,550/$17,100

Primary Care Physician Services

$60 copayment per visit

Doctors Care/Blue CareOnDemand

$60 copayment per visit

Maternity Care

$100 copayment first visit

Specialist Visit

$100 copayment per visit

Urgent Care

$75 copayment per visit

Inpatient Hospital Services

$500 copayment, then 20% after deductible

Outpatient Hospital Services

$500 copayment, then 20% after deductible

Emergency Room

$500 copayment, then 20% after deductible

Ambulance

20% 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: $40 retail/$80 mail order;
Tier 2: $40 retail/$80 mail order;
Tier 3: 20% after deductible retail/20% after deductible mail order;
Tier 4: 20% after deductible retail/20% after deductible mail order

Specialty Pharmaceuticals

Tier 5: 20% after deductible retail/20% after deductible mail order;
Tier 6: 20% after deductible retail/20% after deductible mail order

Durable Medical Equipment

20% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

20% 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.

Weight: 
-5