HSA Qualified 7050 Bronze – Choice Network

56707OR1420003
Expanded Bronze
EPO

HSA Qualified 7050 Bronze – Choice Network is an Expanded Bronze EPO plan by Providence Health Plan.

IMPORTANT: You are viewing the 2023 version of HSA Qualified 7050 Bronze – Choice Network 56707OR1420003. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

HSA Qualified 7050 Bronze – Choice Network is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of HSA Qualified 7050 Bronze – Choice Network 56707OR1420003.
Insurer: Providence Health Plan
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: Yes
Plan ID: 56707OR1420003

Cost-Sharing Overview

HSA Qualified 7050 Bronze – Choice Network offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for HSA Qualified 7050 Bronze - Choice Network?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

HSA Qualified 7050 Bronze – Choice Network offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: All Non-PCP Providers
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what HSA Qualified 7050 Bronze – Choice Network covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency Care and Urgent Care
National Network: No

Additional Benefits and Cost-Sharing

HSA Qualified 7050 Bronze – Choice Network includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
0.00% Coinsurance after deductible 100.00%
Specialist Visit
Covered
0.00% Coinsurance after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
0.00% Coinsurance after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
0.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
0.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
0.00% Coinsurance after deductible 100.00% Respite care provided in a nursing facility subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
0.00% Coinsurance after deductible 0.00% Coinsurance after deductible
Home Health Care Services
Covered
0.00% Coinsurance after deductible 100.00%
Emergency Room Services
Covered
0.00% Coinsurance after deductible 0.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
0.00% Coinsurance after deductible 0.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
0.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
0.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Covered
0.00% Coinsurance after deductible 100.00% Covered when medically necessary due to trauma or disease, or to correct congenital deformities and anomalies.
Skilled Nursing Facility
Covered
0.00% Coinsurance after deductible 100.00%60 Days per Year
Prenatal and Postnatal Care
Covered
No Charge after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
0.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
0.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Inpatient Services
Covered
0.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
0.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Inpatient Services
Covered
0.00% Coinsurance after deductible 100%
Generic Drugs
Covered
0.00% Coinsurance after deductible 100.00%30 Days per Month The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $80 max out of pocket for 30 day supply prior to deductible.
Preferred Brand Drugs
Covered
0.00% Coinsurance after deductible 100.00%30 Days per Month The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $80 max out of pocket for 30 day supply prior to deductible.
Non-Preferred Brand Drugs
Covered
0.00% Coinsurance after deductible 100.00%30 Days per Month The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $80 max out of pocket for 30 day supply prior to deductible.
Specialty Drugs
Covered
0.00% Coinsurance after deductible 100.00%30 Days per Month The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $80 max out of pocket for 30 day supply prior to deductible.
Outpatient Rehabilitation Services
Covered
0.00% Coinsurance after deductible 100.00%30 Visit(s) per Year All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions.
Habilitation Services
Covered
0.00% Coinsurance after deductible 100.00%30 Visit(s) per Year All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions.
Chiropractic Care
Covered
$25.00 Copay after deductible 100.00%20 Visit(s) per Year
Durable Medical Equipment
Covered
0.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
0.00% Coinsurance after deductible 100.00%2 Item(s) per 3 Years 1 hearing aid per ear every 3 years.
Imaging (CT/PET Scans, MRIs)
Covered
0.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Covered
0.00% Coinsurance after deductible 100.00% Covered for patients with diabetes mellitus.
Acupuncture
Covered
$25.00 Copay after deductible 100.00%12 Visit(s) per Year
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%
Eye Glasses for Children
Covered
No Charge 100.00%
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
0.00% Coinsurance after deductible 100.00%30 Visit(s) per Year All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
0.00% Coinsurance after deductible 100.00%30 Visit(s) per Year All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
0.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
0.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Covered
0.00% Coinsurance after deductible 100.00% Covered when medically necessary due to trauma or disease, or to correct congenital deformities and anomalies.
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Covered
0.00% Coinsurance after deductible 100.00% Covered when medically necessary due to trauma or disease, or to correct congenital deformities and anomalies.
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
0.00% Coinsurance after deductible 100.00%
Accidental Dental
Covered
0.00% Coinsurance after deductible 100.00%
Dialysis
Covered
0.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
0.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
0.00% Coinsurance after deductible 100.00%
Radiation
Covered
0.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
No Charge 100.00%
Prosthetic Devices
Covered
0.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
0.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Not Covered
Nutritional Counseling
Covered
No Charge 100.00%
Reconstructive Surgery
Covered
0.00% Coinsurance after deductible 100.00% Covered when medically necessary due to trauma or disease, or to correct congenital deformities and anomalies.
Gender Affirming Care
Covered
Information about gender affirming care can be found in plan documents.
Telehealth – Primary Care Visit
Covered
0.00% Coinsurance after deductible 100.00% All other Telehealth visits same cost share as PCP in-person visits
Telehealth – Specialist
Covered
0.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following HSA Qualified 7050 Bronze – Choice Network preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for HSA Qualified 7050 Bronze – Choice Network including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for HSA Qualified 7050 Bronze - Choice Network?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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