Standard Expanded Bronze - 41047OH0010069 Health Insurance Plan
Buckeye Community Health Plan health insurance plan with the Plan ID 41047OH0010069. The plan is called Standard Expanded Bronze.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.81% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 36.19% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 41047OH0010069 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Ohio | ||||||||||||||||||
| Health Insurance Issuer | Buckeye Community Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 41047OH0010069-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Sep 2025 15:17 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 41047OH0010069-00 Standard On Exchange Plan - 41047OH0010069-01 |
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| Last Plan Update Date | Mon, 12 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Sep 2025 15:17 GMT |
Benefits of Standard Expanded Bronze Health Insurance Plan, 41047OH0010069-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Limit: 3000.0 Dollars per Episode Exclusions: nan Limited to $3,000 per occurrence. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
YES | $100.00 |
100.00% |
| Bariatric Surgery
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Year Exclusions: nan nan |
YES | $100.00 |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: nan nan |
YES | $100.00 |
100.00% |
| Dialysis
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Exclusions: nan Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| ER Diagnostic Test Lab-work/Other
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| ER Diagnostic Test (X-Ray)
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| ER Imaging Test
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| ER Physician Fee
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan Coverage includes benefits specified in the FEDVIP FEP Blue Vision High Option plan, including low vision benefits. |
YES | No Charge |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Exclusions: nan Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information. |
YES | $25.00 |
100.00% |
| Habilitation Services
Exclusions: nan No limit applies to outpatient habilitation services. Inpatient habilitation services are limited to 60 Days per year. |
YES | $50.00 |
100.00% |
| Hearing Aids
Exclusions: nan Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit. |
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Year Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Exclusions: nan Limited to 14 days per lifetime for respite care covered in conjunction with hospice services. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Exclusions: nan Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Emergency Room
Exclusions: nan Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Emergency Transportation/Ambulance
Exclusions: nan Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health ER Physician Fee
Exclusions: nan Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services
Exclusions: nan Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
Exclusions: nan Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | $50.00 |
100.00% |
| Mental/Behavioral Health Urgent Care
Exclusions: nan Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $50.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan nan |
YES | $100.00 Copay after deductible |
100.00% |
| Nutritional Counseling
Exclusions: nan nan |
YES | $100.00 |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 116.0 Visit(s) per Year Exclusions: nan Per year, outpatient cardiac therapy is limited to 36 visits, outpatient pulmonary therapy is limited to 20 visits, outpatient speech, occupational and physical therapy are limited to 20 visits each. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | $50.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: nan nan |
YES | $50.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan Services with an 'A' or 'B' rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration. |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Private-Duty Nursing
Limit: 90.0 Visit(s) per Year Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: nan 1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality; 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer 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. Prior Authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year Exclusions: nan 20 visits per year each for outpatient physical & occupational therapy. Inpatient rehabilitation limited to 60 Days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | $50.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Exclusions: nan 20 visits per year for outpatient speech therapy. Inpatient rehabilitation limited to 60 Days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | $50.00 |
100.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Exclusions: nan Coverage includes benefits specified in the FEDVIP FEP Blue Vision High Option plan, including low vision benefits. |
YES | No Charge |
100.00% |
| Routine Foot Care
Exclusions: nan nan |
YES | $100.00 |
100.00% |
| Skilled Nursing Facility
Limit: 90.0 Days per Year Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $100.00 |
100.00% |
| Specialty Drugs
Exclusions: nan nan |
YES | $500.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | $50.00 |
100.00% |
| Substance Use Disorder Emergency Room
Exclusions: nan Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Use Disorder Emergency Transportation/Ambulance
Exclusions: nan Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Use Disorder ER Physician Fee
Exclusions: nan Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Use Disorder Outpatient Other Services
Exclusions: nan Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Use Disorder Urgent Care
Exclusions: nan Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $50.00 |
100.00% |
| Transplant
Exclusions: nan Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $75.00 |
100.00% |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
Standard Expanded Bronze Health Insurance Plan Variant 41047OH0010069-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.638091065338329 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Diabetes, Heart Disease, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | OHF007 |
| Formulary URL | URL |
| HIOS Product ID | 41047OH001 |
| Import Date | 2024-08-12 20:01:40 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 41047 |
| Issuer Marketplace Marketing Name | Ambetter from Buckeye Health Plan |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | OHN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 41047OH0010069-00 |
| Plan Marketing Name | Standard Expanded Bronze |
| Plan Type | HMO |
| Plan Variant Marketing Name | Standard Expanded Bronze |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,200 |
| SBC Scenario, Having a Baby, Copayment | $60 |
| SBC Scenario, Having a Baby, Deductible | $7,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $4,000 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,100 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OHS001 |
| Source Name | SERFF |
| Plan ID | 41047OH0010069 |
| State Code | OH |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $15000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Standard Expanded Bronze Health Insurance Plan, 41047OH0010069
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Standard Expanded Bronze, 41047OH0010069 Health Insurance Plan, 41047OH0010069
-
Does Standard Expanded Bronze Health Insurance Plan, 41047OH0010069 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (41047OH0010069) Health Insurance Plan, Variant (41047OH0010069-00) offer Disease Management Programs?
Does (41047OH0010069) Health Insurance Plan, Variant (41047OH0010069-00) have Out Of Country Coverage?
Does (41047OH0010069) Health Insurance Plan, Variant (41047OH0010069-00) have Out of Service Area Coverage?
Does (41047OH0010069) Health Insurance Plan, Variant (41047OH0010069-00) offer Disease Management Programs?
Does Standard Expanded Bronze Health Insurance Plan, Variant (41047OH0010069-00) offer Disease Management Programs for Asthma?
Does Standard Expanded Bronze Health Insurance Plan, Variant (41047OH0010069-00) offer Disease Management Programs for Heart disease?
Does Standard Expanded Bronze Health Insurance Plan, Variant (41047OH0010069-00) offer Disease Management Programs for Diabetes?
Does Standard Expanded Bronze Health Insurance Plan, Variant (41047OH0010069-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 16 Sep 2025 15:17 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API