Select Health Med Exp Bronze 9400 – no referrals or deductible for office visits – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $25 copay
Specialist visit: $90 copay
Urgent care visit: $45 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $9,400 per person $9,400 per person |
| Out-of-pocket max | $9,400 per person $18,800 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $25 copay |
| Specialist visit | $90 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $45 copay |
| Emergency room | No charge after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | No charge after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $45 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | No charge after deductible |
Pharmacy, Drugs, and Medication
| Generic | $40 copay |
| Brand | No charge after deductible |
| Non-preferred Brand | No charge after deductible |
| Specialty | No charge after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $100 copay |
| Imaging (CT/PET/MRI) | No charge after deductible |
| Blood work | $100 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $25 copay |
| Psychiatric hospital stay | No charge after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/QtJPwHcqYNeuDbZCcTaavGjF.pdf |
