Bronze 8550

Plan type:

Details: 
Plan BenefitsIn Network Only
Coinsurance

0%

Deductible (single/family)

$8,550/$17,100

Maximum Out Of Pocket (single/family)

$8,550/$17,100

Primary Care Physician Services

$70 copayment per visit

Doctors Care/Blue CareOnDemand

$70 copayment per visit

Maternity Care

$100 first visit

Specialist Visit

$100 copayment per visit

Urgent Care

$75 copayment per visit

Freestanding Ambulatory Surgical Center

$200 copayment per visit

Inpatient Hospital Services

Deductible

Outpatient Hospital Services

Deductible

Emergency Room

Deductible

Ambulance

Deductible

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: Deductible retail/Deductible mail order;
Tier 4: Deductible retail/Deductible mail order

Specialty Pharmaceuticals

Tier 5: Deductible retail/Deductible mail order;
Tier 6: $Deductible retail/Deductible mail order

Durable Medical Equipment

Deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation

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: 
-1