Find Health Plans

Bronze HMO BlueCare Prime with Added Dental and Vision Benefits

86545CT1230025
Expanded Bronze
HMO

Bronze HMO BlueCare Prime with Added Dental and Vision Benefits is an Expanded Bronze HMO plan by Anthem Blue Cross and Blue Shield.

Locations

Bronze HMO BlueCare Prime with Added Dental and Vision Benefits is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of Bronze HMO BlueCare Prime with Added Dental and Vision Benefits 86545CT1230025.
Insurer: Anthem Blue Cross and Blue Shield
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 86545CT1230025

Cost-Sharing Overview

Bronze HMO BlueCare Prime with Added Dental and Vision Benefits 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 HMO BlueCare Prime with Added Dental and Vision Benefits?

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 HMO BlueCare Prime with Added Dental and Vision Benefits offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Low Back Pain, High Blood Pressure & High Cholesterol
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: All specialists require referral with the exception of OB/GYN
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Bronze HMO BlueCare Prime with Added Dental and Vision Benefits 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 HMO BlueCare Prime with Added Dental and Vision Benefits includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor.
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Non-emergency ambulance/transportation out of network is not covered unless authorized. Authorized out of network is limited to $50,000 per occurrence.
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Eye Exam (Adult)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Hospice Bereavement is not covered. Life Expectancy of 12 months or less and if the care is Pre-Authorized or Pre-Certified.
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per 2 Years Limited to 1 per ear per member every 2 years. Limits are combined for INN and OON.Substantially Equal
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Visit(s) per Year 40 visits per person per year for Physical/Occupational/Speech Therapies combined. Medically necessary treatment of Autism Spectrum Disorder is covered. Limitations do not apply to Autism Spectrum Disorder diagnosis.Substantially Equal
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Visit(s) per Year 40 visits per person per year for Physical/Occupational/Speech Therapies combined. Medically necessary treatment of Autism Spectrum Disorder is covered. Limitations do not apply to Autism Spectrum Disorder diagnosis.Substantially Equal
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Includes coverage for Breast Tomosynthesis
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Visit(s) per Year Substantially Equal
Routine Dental Services (Adult)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Bones/Joints
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Bone Marrow Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No The coinsurance for prosthetic arms, or legs, including one with a microprocessor if medically necessary cannot exceed 20%.
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Other Law/Regulation
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Donor search charges are limited to 10 best matched donors identified by an authorized registry.
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Visit(s) per Year 40 visits per person per year for Physical/Occupational/Speech Therapies combined. Medically necessary treatment of Autism Spectrum Disorder is covered. Limitations do not apply to Autism Spectrum Disorder diagnosis.Substantially Equal
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Limited reimbursementSubstantially Equal
Acupuncture
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covered for pain management onlyAdditional EHB Benefit
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Accidental Ingestion of a Controlled Drug
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Some PT and surgery covered.
Orthodontia – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Medically necessary services only
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No10 Hours per Lifetime Benefits are provided for 10 hours of initial training, 4 hours of additional training because of changes in the individual’s condition and four hours of training required by new developments in the treatment of diabetes.Substantially Equal
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Developmental Needs of Children & Youth with Cancer
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply. Retail Tier 3 and Tier 4 fill coinsurance is limited to a specific maximum per prescription, depending on your specific plan.
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No100 Visit(s) per Year Subject to a separate $50 deductible for in networkSubstantially Equal
Basic Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Dental Check-Up for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No2 Visit(s) per Year Substantially Equal
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor.
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply.
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor.
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Early Intervention Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Inherited Metabolic Disorder – PKU
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Private-Duty Nursing
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Emergency Room copay is waived if directly admitted to the hospital.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Visit(s) per Year 40 visits per person per year for Physical/Occupational/Speech Therapies combined. Medically necessary treatment of Autism Spectrum Disorder is covered. Limitations do not apply to Autism Spectrum Disorder diagnosis.Substantially Equal
Diabetes Care Management
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Abortion for Which Public Funding is Prohibited
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Limited to therapeutic (only in case of rape, incest or health of mother.Not EHB
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Up to a combined annual maximum cost share of $375 for MRI and CAT scans; $400 for PET scans.
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No2 Visit(s) per Year For Illnesses requiring therapeutic dietary monitoring, including the diagnosis of obesity limited to 2 visits per year.Substantially Equal
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No90 Days per Year Substantially Equal
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply.
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Exam(s) per Year Limited reimbursementSubstantially Equal
Major Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Visit(s) per Year Additional EHB Benefit
Mammography Ultrasound
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Benefit limited to the following lifetime cycles: 4 cycles for ovulation induction, 3 cycles for intrauterine insemination, 2 cycles combined for in-vitro fertilization, GIFT, ZIFT, and Low Tubal Ovum Transfer.
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Post-Mastectomy Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Treatment of Medical Complications of Alcoholism
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Bariatric Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply. Retail Tier 3 and Tier 4 fill coinsurance is limited to a specific maximum per prescription, depending on your specific plan.
Wound Care for Individuals with Epidermolysis Bullosa
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No

Free Preventive Services

There is no copayment or coinsurance for any of the following Bronze HMO BlueCare Prime with Added Dental and Vision Benefits 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.

Ready to sign up for Bronze HMO BlueCare Prime with Added Dental and Vision Benefits?

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

Table of Contents