Bronze Essential 8500 With 4 Copay No Deductible Office Visits

22013UT2650008
Expanded Bronze
EPO

Bronze Essential 8500 With 4 Copay No Deductible Office Visits is an Expanded Bronze EPO plan by Regence BlueCross BlueShield of Utah.

IMPORTANT: You are viewing the 2023 version of Bronze Essential 8500 With 4 Copay No Deductible Office Visits 22013UT2650008. You can enroll in this plan during open enrollment 2023, which started November 1st and ends January 15th, 2023, in most states.

Locations

Bronze Essential 8500 With 4 Copay No Deductible Office Visits is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Bronze Essential 8500 With 4 Copay No Deductible Office Visits 22013UT2650008.
Insurer: Regence BlueCross BlueShield of Utah
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 22013UT2650008

Cost-Sharing Overview

Bronze Essential 8500 With 4 Copay No Deductible Office Visits 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 Bronze Essential 8500 With 4 Copay No Deductible Office Visits?

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

Bronze Essential 8500 With 4 Copay No Deductible Office Visits offers the following features and referral requirements.

Wellness Program: No
Disease Program:
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Bronze Essential 8500 With 4 Copay No Deductible Office Visits covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description:
National Network: No

Additional Benefits and Cost-Sharing

Bronze Essential 8500 With 4 Copay No Deductible Office Visits includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Eye Glasses for Children
Covered
No Charge No Charge 100.00%1 Item(s) per Year One pair of lenses and one frame per year (contacts in lieu of glasses)
Dental Check-Up for Children
Covered
No Charge No Charge 100.00%2 Exam(s) per Year
Rehabilitative Speech Therapy
Covered
10.00% Coinsurance after deductible 100.00%20 Visit(s) per Benefit Period Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. Visit limit does not apply to Mental Health/Substance Abuse.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
10.00% Coinsurance after deductible 100.00%20 Visit(s) per Benefit Period Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. Visit limit does not apply to Mental Health/Substance Abuse.
Well Baby Visits and Care
Covered
No Charge No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
10.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
10.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Primary Care Visit to Treat an Injury or Illness
Covered
$60.00 10.00% Coinsurance after deductible 100.00% The first 4 in -network PCP, in-network Specialists, and Urgent Care office visits combined per calendar year are not subject to the deductible.
Specialist Visit
Covered
$60.00 10.00% Coinsurance after deductible 100.00% The first 4 in -network PCP, in-network Specialists, and Urgent Care office visits combined per calendar year are not subject to the deductible.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$60.00 10.00% Coinsurance after deductible 100.00% The first 4 in -network PCP, in-network Specialists, and Urgent Care office visits combined per calendar year are not subject to the deductible.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
10.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
10.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
10.00% Coinsurance after deductible 100.00%6 Months per 3 Years
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
$60.00 10.00% Coinsurance after deductible$60.00 10.00% Coinsurance after deductible Out of service area coverage is available. The first 4 in-network PCP, in-network Specialists, and Urgent Care office visits combined per calendar year are not subject to the deductible.
Home Health Care Services
Covered
10.00% Coinsurance after deductible 100.00%30 Visit(s) per Benefit Period
Emergency Room Services
Covered
10.00% Coinsurance after deductible 10.00% Coinsurance after deductible Out of service area coverage is available.
Emergency Transportation/Ambulance
Covered
10.00% Coinsurance after deductible 10.00% Coinsurance after deductible Out of service area coverage is available.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
10.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
10.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
10.00% Coinsurance after deductible 100.00%30 Visit(s) per Benefit Period 30 days per year for Inpatient Rehabilitation and Skilled Nursing Facility combined
Prenatal and Postnatal Care
Covered
10.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
10.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
10.00% Coinsurance after deductible 100.00% Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Mental/Behavioral Health Inpatient Services
Covered
10.00% Coinsurance after deductible 100.00% Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Substance Abuse Disorder Outpatient Services
Covered
10.00% Coinsurance after deductible 100.00% Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Substance Abuse Disorder Inpatient Services
Covered
10.00% Coinsurance after deductible 100.00% Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Generic Drugs
Covered
$15.00 100.00% insulin limit of? $27 per 30 days? $81 for 90 day supply
Preferred Brand Drugs
Covered
20.00% Coinsurance after deductible 100.00% insulin limit of? $27 per 30 days? $81 for 90 day supply
Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00% insulin limit of? $27 per 30 days? $81 for 90 day supply
Specialty Drugs
Covered
40.00% Coinsurance after deductible 100.00% First fill allowed at a retail pharmacy. Insulin limit of $27 per 30 days, $81 for 90 day-supply
Outpatient Rehabilitation Services
Covered
10.00% Coinsurance after deductible 100.00%20 Visit(s) per Benefit Period Combined rehabilitative limit for outpatient physical, occupational and speech therapies. 20 outpatient visits per year. Visit limit does not apply to Mental Health/Substance Abuse.
Habilitation Services
Covered
10.00% Coinsurance after deductible 100.00%20 Visit(s) per Benefit Period Habilitation services limited to 30 inpatient days per year and 20 outpatient visits per year.
Chiropractic Care
Not Covered
Durable Medical Equipment
Covered
10.00% Coinsurance after deductible 100.00% Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
10.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge No Charge 100.00%
Routine Foot Care
Covered
10.00% Coinsurance after deductible 100.00% Covered when medically necessary.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Exam(s) per Year
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
10.00% Coinsurance after deductible 100.00%
Accidental Dental
Not Covered
Dialysis
Covered
10.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
10.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
10.00% Coinsurance after deductible 100.00%
Radiation
Covered
10.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
No Charge No Charge 100.00%
Prosthetic Devices
Covered
10.00% Coinsurance after deductible 100.00% Limited covered services.
Infusion Therapy
Covered
10.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Not Covered
Nutritional Counseling
Covered
10.00% Coinsurance after deductible 100.00%
Reconstructive Surgery
Covered
10.00% Coinsurance after deductible 100.00% Covers mastectomy in the treatment of cancer and reconstructive surgery after a mastectomy.
Gender Affirming Care
Covered
10.00% Coinsurance after deductible 100.00%
Diabetes Care Management
Covered
10.00% Coinsurance after deductible 100.00%
Inherited Metabolic Disorder – PKU
Covered
10.00% Coinsurance after deductible 100.00%
Autism Spectrum Disorders
Covered
10.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Bronze Essential 8500 With 4 Copay No Deductible Office Visits 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 Bronze Essential 8500 With 4 Copay No Deductible Office Visits 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 Bronze Essential 8500 With 4 Copay No Deductible Office Visits?

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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