HeartlandBlue Bronze HSA 6500 Premier Select BlueChoice – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$6,500 per person $6,500 per person
Out-of-pocket max	$8,050 per person $16,100 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	20% coinsurance after deductible
Specialist visit	20% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	20% coinsurance after deductible
Emergency room	20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	20% coinsurance after deductible
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	20% coinsurance after deductible
Brand	50% coinsurance after deductible
Non-preferred Brand	55% coinsurance after deductible
Specialty	60% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	20% coinsurance after deductible
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://sbc.nebraskablue.com/home/retrievesbc/M23123002_2024.pdf
Drug and medication plan formulary	https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_NE_6T_HealthInsuranceMarketplace.pdf
Search doctor list	https://bcbsne.healthsparq.com/healthsparq/public/#/one/&state=NE&postalCode=&country=US&insurerCode=BCBSNE_I&brandCode=BCBSNE&productCode=1002001002