PPO HSA 5000 – Flex – PPO
Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: $75 copay after deductible
Specialist visit: $150 copay after deductible
Urgent care visit: $150 copay after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | N/A N/A |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $75 copay after deductible |
| Specialist visit | $150 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $150 copay after deductible |
| Emergency room | $1,500 copay after deductible |
| Ambulance | $250 copay after deductible |
| Hospital stay (facility) | $1,500 copay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $1,000 copay after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $40 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $1,500 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay after deductible |
| Brand | 50% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible, up to $500 copay, 50% after deductible, up to $500 |
Lab Tests and Diagnostic Procedures
| X-rays | $150 copay after deductible |
| Imaging (CT/PET/MRI) | $500 copay after deductible |
| Blood work | $75 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $75 copay after deductible |
| Psychiatric hospital stay | $1,500 copay after deductible |
