AvMed Entrust Bronze 625 Dental+Vision (2023)

19898FL0350046
Expanded Bronze
HMO

AvMed Entrust Bronze 625 Dental+Vision (2023) is an Expanded Bronze HMO plan by AvMed.

IMPORTANT: You are viewing the 2023 version of AvMed Entrust Bronze 625 Dental+Vision (2023) 19898FL0350046. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

AvMed Entrust Bronze 625 Dental+Vision (2023) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of AvMed Entrust Bronze 625 Dental+Vision (2023) 19898FL0350046.
Insurer: AvMed
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 19898FL0350046

Cost-Sharing Overview

AvMed Entrust Bronze 625 Dental+Vision (2023) 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 AvMed Entrust Bronze 625 Dental+Vision (2023)?

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

AvMed Entrust Bronze 625 Dental+Vision (2023) offers the following features and referral requirements.

Wellness Program: No
Disease Program:
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: All except OB/Gyn, Chiropractor, and Podiatrist for diabetic foot care.
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what AvMed Entrust Bronze 625 Dental+Vision (2023) 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 Only
National Network: No

Additional Benefits and Cost-Sharing

AvMed Entrust Bronze 625 Dental+Vision (2023) 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
$70.00 100.00%
Specialist Visit
Covered
$140.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$70.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
$1,000.00 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
$300.00 100.00%
Hospice Services
Covered
No Charge 100.00%
Routine Dental Services (Adult)
Covered
No Charge 100.00%
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Covered
No Charge 100.00%
Urgent Care Centers or Facilities
Covered
$125.00 $250.00
Home Health Care Services
Covered
$140.00 100.00%20 Visit(s) per Benefit Period
Emergency Room Services
Covered
$1,850.00 $1,850.00
Emergency Transportation/Ambulance
Covered
$200.00 $200.00
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
$3,000.00 Copay per Day 100.00%
Inpatient Physician and Surgical Services
Covered
No Charge 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
$250.00 Copay per Stay 100.00%60 Days per Benefit Period
Prenatal and Postnatal Care
Covered
$70.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
$3,000.00 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$70.00 100.00%20 Visit(s) per Benefit Period
Mental/Behavioral Health Inpatient Services
Covered
$3,000.00 Copay per Day 100.00%30 Days per Benefit Period
Substance Abuse Disorder Outpatient Services
Covered
$70.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
$3,000.00 Copay per Day 100.00%
Generic Drugs
Covered
$25.00 100.00%
Preferred Brand Drugs
Covered
$85.00 Copay after deductible 100.00%
Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Specialty Drugs
Covered
40.00% Coinsurance after deductible 100.00%
Outpatient Rehabilitation Services
Covered
$140.00 100.00%35 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic.
Habilitation Services
Covered
$140.00 100.00%35 Visit(s) per Benefit Period Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Chiropractic Care
Covered
$70.00 100.00%35 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic.
Durable Medical Equipment
Covered
$100.00 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
$500.00 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00% Preventive colonoscopy (age 50+) 1 every 10 years. High risk colonoscopy – 1 every 2 years.
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Benefit Period
Dental Check-Up for Children
Covered
No Charge 100.00%1 Exam(s) per 6 Months Bundled with medical through separate dental provider
Rehabilitative Speech Therapy
Covered
$140.00 100.00%35 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$140.00 100.00%35 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
$50.00 100.00%
X-rays and Diagnostic Imaging
Covered
$95.00 100.00%
Basic Dental Care – Child
Covered
No Charge 100.00% Bundled with medical through separate dental provider
Orthodontia – Child
Covered
$375.00 100.00% Bundled with medical through separate dental provider
Major Dental Care – Child
Covered
$375.00 100.00% Bundled with medical through separate dental provider
Basic Dental Care – Adult
Covered
No Charge 100.00%
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
$3,000.00 100.00%
Accidental Dental
Covered
$3,000.00 100.00%
Dialysis
Covered
$1,000.00 100.00%
Allergy Testing
Covered
$140.00 100.00%
Chemotherapy
Covered
50.00% 100.00%
Radiation
Covered
$1,000.00 100.00%
Diabetes Education
Covered
$140.00 100.00%
Prosthetic Devices
Covered
$100.00 100.00%
Infusion Therapy
Covered
$140.00 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
$140.00 100.00%
Nutritional Counseling
Covered
$140.00 100.00%3 Visit(s) per Benefit Period Diabetes coverage includes ‘nutrition counseling’; home health services include ‘nutritional guidance.’
Reconstructive Surgery
Covered
$3,000.00 100.00% Only for Breast reconstruction following a Mastectomy.
Gender Affirming Care
Not Covered
Bone Marrow Transplant
Covered
$3,000.00 100.00%
Congenital Anomaly, including Cleft Lip/Palate
Covered
$3,000.00 100.00%
Dental Anesthesia
Covered
No Charge 100.00%
Diabetes Care Management
Covered
$140.00 100.00% In order for services to be covered, diabetes care management must be provided under the direct supervision of a certified diabetes educator or board certified physician specializing in endocrinology.
Nutrition/Formulas
Covered
$100.00 100.00%
Osteoporosis
Covered
$500.00 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following AvMed Entrust Bronze 625 Dental+Vision (2023) 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 AvMed Entrust Bronze 625 Dental+Vision (2023) 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 AvMed Entrust Bronze 625 Dental+Vision (2023)?

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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