Bronze 7300

Plan type:

Details: 
Plan BenefitsIn Network Only
Coinsurance

50%

Deductible (single/family)

$7,300/$14,600

Maximum Out Of Pocket (single/family)

$8,550/$17,100

Primary Care Physician Services

$65 copayment per visit

Doctors Care/Blue CareOnDemand

$65 copayment per visit

Maternity Care

$100 first visit

Specialist Visit

$100 copayment per visit

Urgent Care

$75 copayment per visit

Inpatient Hospital Services

$500 copayment, then 50% after deductible

Outpatient Hospital Services

$500 copayment, then 50% after deductible

Emergency Room

$500 copayment, then 50% after deductible

Ambulance

50% 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: 50% after deductible retail/50% after deductible mail order;
Tier 4: 50% after deductible retail/50% after deductible mail order

Specialty Pharmaceuticals

Tier 5: 50% after deductible retail/50% after deductible mail order;
Tier 6: 50% after deductible retail/50% after deductible mail order

Durable Medical Equipment

50% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

50% 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: 
-3