SELECT BRONZE I205-01 VALUE TIER RX W/DENTAL – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $75 copay
Specialist visit: $155 copay
Urgent care visit: $155 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $75 copay |
| Specialist visit | $155 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $155 copay |
| Emergency room | $1,500 copay |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | $3,000 per day copay |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | $2,000 copay |
| Outpatient procedure (physician) | 50% coinsurance |
| Physical rehabilitation | $155 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $3,000 per day copay |
Pharmacy, Drugs, and Medication
| Generic | $15 per script copay |
| Brand | $15 per script copay |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $155 per day copay |
| Imaging (CT/PET/MRI) | $1,000 per day copay |
| Blood work | $75 per day copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $75 copay |
| Psychiatric hospital stay | $3,000 per day copay |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/Q2oxSy7XaEKXFGNVXVjVobuJ.pdf |
| Drug and medication plan formulary | https://quartzbenefits.com/members/pharmacy-program/covered-drugs/standard-formularies/ |
