Bronze Plan Standardized

75293AR1200027
Bronze
PPO

Bronze Plan Standardized is a Bronze PPO plan by Arkansas Blue Cross and Blue Shield.

IMPORTANT: You are viewing the 2023 version of Bronze Plan Standardized 75293AR1200027. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Bronze Plan Standardized is offered in the following counties.

No data was found

Plan Overview

This is a plan overview for 2023 version of Bronze Plan Standardized 75293AR1200027.
Insurer: Arkansas Blue Cross and Blue Shield
Network Type: PPO
Metal Type: Bronze
HSA Eligible?: No
Plan ID: 75293AR1200027

Cost-Sharing Overview

Bronze Plan Standardized 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 Plan Standardized?

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 Plan Standardized offers the following features and referral requirements.

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

Network Details

The following network details will help you understand what Bronze Plan Standardized 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 Care
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Benefit Reduction
National Network: No

Additional Benefits and Cost-Sharing

Bronze Plan Standardized 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
No Charge after deductible 50.00% Coinsurance after deductible
Specialist Visit
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Outpatient Surgery Physician/Surgical Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Hospice Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company. If the Covered Person has been diagnosed and certified by the attending Physician as having a terminal illness with a life expectancy of six months or less, the Company will pay the Allowance or Allowable Charge for Hospice Care. The services must be rendered by an entity licensed by the Arkansas Department of Health or other appropriate state licensing agency and accepted by the Company as a Provider. This benefit is subject to the Deductible, Copayment and Coinsurance specified in the Schedule of Benefits.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
No Charge after deductible 100.00% Requires Prior Approval from the Company. 4 oocyte retrievals or 2 live births from separate pregnancies
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Covered
No Charge No Charge 100.00%1 Visit(s) per 2 Years
Urgent Care Centers or Facilities
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Home Health Care Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible50 Visit(s) per Year Requires Prior Approval from the Company. Coverage is provided for Home Health Services when Coverage Policy supports the need for in-home service and such care is prescribed or ordered by a Physician. Covered Services must be provided through and billed by a licensed home health agency. Covered Services provided in the home include services of a Registered Professional Nurse (R.N.), a Licensed Practical Nurse (L.P.N.) or a Licensed Psychiatric Technical Nurse (L.P.T.N.).
Emergency Room Services
Covered
No Charge after deductible No Charge after deductible
Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
No Charge after deductible 50.00% Coinsurance after deductible60 Days per Year Requires Prior Approval from the Company. 1. The admission must be within seven days of release from an inpatient Hospital stay; 2. The Skilled Nursing Facility services are of a temporary nature and increase ability to function.
Prenatal and Postnatal Care
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Notification to the Company. Coverage for routine ultrasound is limited to 1.
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 50.00% Coinsurance after deductible Childbirth/delivery professional services: 75293AR1200027-01-No Charge after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200027-02-No charge for in-network and out-of-network services; 75293AR1200027-03-No Charge after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; Coverage for Out of Network newborn services is limited to $2000 per person for all services first 90 days after birth. Coverage requires Prior Notification to the Company.
Mental/Behavioral Health Outpatient Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Substance Abuse Disorder Outpatient Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Generic Drugs
Covered
No Charge after deductible 100.00%
Preferred Brand Drugs
Covered
No Charge after deductible 100.00%
Non-Preferred Brand Drugs
Covered
No Charge after deductible 100.00%
Specialty Drugs
Covered
No Charge after deductible 100.00% Requires Prior Approval from the Company.
Outpatient Rehabilitation Services
Covered
No Charge after deductible 100.00%30 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro.
Habilitation Services
Covered
No Charge after deductible 100.00%30 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro; Limited to a maximum of 180 units for developmental services visits per Covered Person per calendar year.
Chiropractic Care
Covered
No Charge after deductible 100.00%30 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro.
Durable Medical Equipment
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company for services $500 or more
Hearing Aids
Covered
No Charge No ChargeNo Charge No Charge Coverage is limited to $1400/ear
Imaging (CT/PET Scans, MRIs)
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company for high tech radiology services
Preventive Care/Screening/Immunization
Covered
No Charge No Charge 100.00%1 Visit(s) per Year
Routine Foot Care
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge No Charge 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
No Charge after deductible 50.00% Coinsurance after deductible1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
No Charge after deductible 100.00%30 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
No Charge after deductible 100.00%30 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro.
Well Baby Visits and Care
Covered
No Charge No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
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
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Accidental Dental
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Dialysis
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Allergy Testing
Covered
No Charge after deductible 50.00% Coinsurance after deductible SOB includes ‘allergy services.’
Chemotherapy
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Radiation
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Diabetes Education
Covered
No Charge No Charge 50.00% Coinsurance after deductible
Prosthetic Devices
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company for any device for which cost exceeds $5,000. Replaced no more frequently than once per 3-yr period except when necessary for growth or end of device’s useful life.
Infusion Therapy
Covered
No Charge after deductible 50.00% Coinsurance after deductible Home infusion therapy.
Treatment for Temporomandibular Joint Disorders
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Nutritional Counseling
Covered
No Charge after deductible 50.00% Coinsurance after deductible Coverage is provided for dietary and nutritional counseling services when provided in conjunction with diabetic self-management training, for services needed by covered persons in connection with cleft palate management and for nutritional assessment programs provided in and by a hospital and approved by the company.
Reconstructive Surgery
Covered
No Charge after deductible 100.00% Requires Prior Approval from the Company. 1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Covered Person; 2. Surgery performed for the removal of a port-wine stain or hemangioma (only on the face) 3. Treatment provided for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria and is Prior Approved by the Company is covered.
Gender Affirming Care
Covered
No Charge after deductible 100.00% Requires Prior Approval from the Company.
Diabetes Care Management
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Inherited Metabolic Disorder – PKU
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Off Label Prescription Drugs
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Dental Anesthesia
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Gastric Electrical Stimulation
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Well Child Care
Covered
No Charge No Charge 100.00%
Applied Behavior Analysis Based Therapies
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Cochlear Implants
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company. One cochlear implant per ear per Covered Person per lifetime
Craniofacial Surgery
Covered
No Charge after deductible 50.00% Coinsurance after deductible Requires Prior Approval from the Company.
Specialty Drugs Tier 2
Covered
No Charge after deductible 100.00% Requires Prior Approval from the Company.
Preventive Drugs
Covered
No Charge No Charge 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Bronze Plan Standardized 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 Plan Standardized 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 Plan Standardized?

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