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Plan Details

silver hmo

BCBSHP Silver Pathway Guided Access HMO 3500

$669.84/mo Monthly Premium:

Plan Cost

$669.84

Network:Pathway X Guided Access, Dental Prime, and Rx Choice Tiered Network

Primary Care Visit:$20

Inpatient Hospital Services:$500/Stay + 50% after ded.

Medical Deductible:$3,500

EHB & Drug OOP Max:$4,850

Annual Deductible
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkCombined
Medical DeductibleIndividual: $3,500 Family: $7,000Individual: $3,500 Family: $7,000Individual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not Applicable
Drug Benefits DeductibleIndividual: $1,000 Family: $2,000Individual: $1,000 Family: $2,000Individual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not Applicable
Annual Out-of-Pocket
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkCombined
Out of Pocket Max for Med and Drug EHB Benefits (Total)Individual: $4,850 Family: $9,700Individual: $4,850 Family: $9,700Individual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not Applicable
Professional Services
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Other Practitioner Office Visit (Nurse, Physician Assistant)$20Not ApplicableNot CoveredSee Brochure
Imaging (CT/PET Scans, MRIs)$300 then 50% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Cost share is driven by provider/setting.
X-rays and Diagnostic Imaging25% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Cost share is driven by provider/setting.
Specialist Visit25% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Chiropractic Care25% Coinsurance after deductibleNot ApplicableNot CoveredLimit: 20 Visit(s) per Year Explanation: Visit limit is combined both across outpatient and other professional visits. Cost share is driven by provider/setting.
Laboratory Outpatient and Professional Services25% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Cost share is driven by provider/setting.
Primary Care Visit to Treat an Injury or Illness$20Not ApplicableNot CoveredSee Brochure
Prescription Drug Coverage
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Generic Drugs$5$15Not CoveredExplanation: 30 day retail supply or 90 day mail order. 2X copay (if applicable) for mail order.
Preferred Brand Drugs$40 Copay after deductible$50 Copay after deductibleNot CoveredExplanation: 30 day retail supply or 90 day mail order. 2.5X copay (if applicable) for mail order.
Non-Preferred Brand Drugs40% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredExplanation: 30 day retail supply or 90 day mail order
Specialty Drugs 40% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredExplanation: 30 day supply only for retail or mail order
Preventative Care
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Well Baby Visits and CareNo ChargeNot ApplicableNot CoveredExplanation: Care provided for birth through age 5.
Preventive Care/Screening/ImmunizationNo ChargeNot ApplicableNot CoveredSee Brochure
Emergency Health
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Urgent Care Centers or Facilities$90Not Applicable$90Explanation: Cost share is driven by provider/setting.
Emergency Room Services$300 then 25% Coinsurance after deductibleNot Applicable$300 then 25% Coinsurance after deductibleExplanation: Copayment (if applicable) is waived if admitted.
Emergency Transportation/Ambulance25% Coinsurance after deductibleNot Applicable25% Coinsurance after deductibleExplanation: Benefits for Non-Emergency ambulance services will be limited to $50,000 per occurrence if a Non-Network Provider is used.
Outpatient Services
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Outpatient Surgery Physician/Surgical Services25% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)25% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Outpatient Rehabilitation Services25% Coinsurance after deductibleNot ApplicableNot CoveredLimit: 20 Visit(s) per Year Explanation: 20 visits for Rehabilitation Speech Therapy and 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy. Certain other therapies may be excluded. Speech Therapy, Occupational
Hospitalization Services
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Inpatient Physician and Surgical Services25% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Habilitation Services25% Coinsurance after deductibleNot ApplicableNot CoveredLimit: 20 Visit(s) per Year Explanation: 20 visits for Habilitation Speech Therapy and 20 visits combined for Habilitation Physical Therapy and Occupational Therapy. Certain other therapies may be excluded. Speech Therapy, Occupational Therapy and Physica
Inpatient Hospital Services (e.g., Hospital Stay)$500 Copay per Stay then 50% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Skilled Nursing Facility25% Coinsurance after deductibleNot ApplicableNot CoveredLimit: 60 Days per year Explanation: Combined days for Inpatient Rehabilitation and Skilled Nursing Facility services.
Substance Abuse Disorder Outpatient Services25% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Cost share is driven by provider/setting.
Substance Abuse Disorder Inpatient Services$500 then 50% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Maternity Care
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Delivery and All Inpatient Services for Maternity Care$500 then 50% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Hospital stay is 48 hours for vaginal delivery and 96 hours for c-section
Prenatal and Postnatal Care25% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Home Health Care
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Home Health Care Services25% Coinsurance after deductibleNot ApplicableNot CoveredLimit: 120 Visit(s) per Year Explanation: Limit does not apply to Physical, Occupational or Speech Therapy when performed as part of Home Health Care Services.
Other Services
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Cosmetic Surgery$500 then 50% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Reconstructive surgery is covered. Reconstructive surgery is performed to correct deformities caused by congenital or developmental abnormalities, illness, injury, or previous therapeutic process, for the purpose of improving bodily function
Mental/Behavioral Health Inpatient Services$500 then 50% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Durable Medical Equipment25% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Hospice Services25% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Mental/Behavioral Health Outpatient Services25% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Cost share is driven by provider/setting.
Weight Loss Programs25% Coinsurance after deductibleNot ApplicableNot CoveredLimit: 4 Visit(s) per Year Explanation: Covered only for treatment of morbid obesity. Excluded Nutritional supplements; services, supplies and/or nutritional sustenance products. Limited to 4 visits per year.
Rehabilitative Speech Therapy25% Coinsurance after deductibleNot ApplicableNot CoveredLimit: 20 Visit(s) per Year Explanation: 20 visits for Rehabilitation Speech Therapy.  Certain other therapies may be excluded.  Speech Therapy  will not apply for children ages 0-6  with Autism (ASD) diagnosis to the service maximums/limits in any therap
Rehabilitative Occupational and Rehabilitative Physical Therapy25% Coinsurance after deductibleNot ApplicableNot CoveredLimit: 20 Visit(s) per Year Explanation: 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy.  Certain other therapies may be excluded.  Occupational Therapy and Physical Therapy will not apply for children ages
Accidental Dental25% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Cost share is driven by provider/setting.
Allergy Testing25% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Cost share is driven by provider/setting.
Chemotherapy25% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Cost share is driven by provider/setting.
Diabetes Education25% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Cost share is driven by provider/setting.
Dialysis25% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Cost share is driven by provider/setting.
Infusion Therapy25% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Cost share is driven by provider/setting.
Nutritional Counseling25% Coinsurance after deductibleNot ApplicableNot CoveredLimit: 4 Visit(s) per Year Explanation: Covered only for treatment of morbid obesity. Excluded Nutritional supplements; services, supplies and/or nutritional sustenance products. Limited to 4 visits per year.
Prosthetic Devices25% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Wigs are limited to 1 (one) per year as needed after cancer treatment. 
Radiation25% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Cost share is driven by provider/setting.
Reconstructive Surgery$500 then 50% Coinsurance after deductibleNot ApplicableNot CoveredExplanation: Reconstructive surgery is covered. Reconstructive surgery is performed to correct deformities caused by congenital or developmental abnormalities, illness, injury, or previous therapeutic process, for the purpose of improving bodily function
Transplant$500 then 50% Coinsurance after deductibleNot ApplicableNot CoveredLimit: 10000 Dollars per Procedure Explanation: In-Network Transplant Transportation and Lodging $10,000 Maximum benefit limit per Transplant Unrelated Donor Search $30,000 Maximum benefit limit per Transplant.
Treatment for Temporomandibular Joint Disorders25% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Additional BenefitsClinical Trials: $500 + 50% after ded.Clinical Trials: N/AClinical Trials: Not CoveredBone Marrow Transplant: Limit: 10000 Dollars per Procedure Explanation: In-Network Transplant Transportation and Lodging $10,000 Maximum benefit limit per Transplant Unrelated Donor Search $30,000 Maximum benefit limit per Transplant.
Dental
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Dental Check-Up for ChildrenNo Charge after deductibleNot ApplicableNot CoveredLimit: 2 Visit(s) per Year
Major Dental Care – Child50% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Basic Dental Care – Child40% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Orthodontia – Child50% Coinsurance after deductibleNot ApplicableNot CoveredSee Brochure
Vision
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Routine Eye Exam for ChildrenNo ChargeNot ApplicableNot CoveredLimit: 1 Visit(s) per Year
Eye Glasses for ChildrenNo ChargeNot ApplicableNot CoveredLimit: 1 Item(s) per Year