(2024) Bronze MI04 HMO – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: first 3 visit(s) $60 then $60 copay after deductible
Specialist visit: first 3 visit(s) $95 then $95 copay after deductible
Urgent care visit: first 3 visit(s) $60 then $60 copay after deductible
Description
Health Care Plan Details
| Network type | HMO |
| 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 | first 3 visit(s) $60 then $60 copay after deductible |
| Specialist visit | first 3 visit(s) $95 then $95 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | first 3 visit(s) $60 then $60 copay after deductible |
| Emergency room | 40% after deductible |
| Ambulance | 40% after deductible |
| 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 | $60 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 40% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $17 copay after deductible |
| Brand | 40% after deductible |
| Non-preferred Brand | 40% after deductible |
| Specialty | 40% after deductible, up to $500 copay, 40% after deductible, up to $500 |
Lab Tests and Diagnostic Procedures
| X-rays | 40% after deductible |
| Imaging (CT/PET/MRI) | 40% after deductible |
| Blood work | $40 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 3 visit(s) $60 then $60 copay |
| Psychiatric hospital stay | 40% after deductible |
