MySHL Solutions EPO Bronze 14 – EPO
Network type: EPO
Coverage tier: Bronze
Primary care visit: $30 copay
Specialist visit: $60 copay after deductible
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | See brochure See brochure |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Bronze |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $60 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $600 copay after deductible |
| Ambulance | $100 copay |
| Hospital stay (facility) | 40% after deductible |
| Hospital stay (physician) | 40% after deductible |
| Outpatient procedure (facility) | 40% after deductible |
| Outpatient procedure (physician) | 40% after deductible |
| Physical rehabilitation | $30 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 40% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 per script copay |
| Brand | $75 per script copay |
| Non-preferred Brand | $75 per script after deductible copay |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $50 per procedure after deductible copay |
| Imaging (CT/PET/MRI) | 40% after deductible |
| Blood work | $50 per procedure after deductible copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | 40% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/XrBHBtwYVvRQuJ8WLDbLYjKh.pdf |
| Drug and medication plan formulary | https://www.sierrahealthandlife.com/Member |
