Elevate Health Plans Colorado Option Bronze – HMO

Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: first 3 visit(s) $0 then $50 copay after deductible
Specialist visit: first 3 visit(s) $0 then 50% after deductible copay, first 3 visit(s) $0 then 50% after deductible
Urgent care visit: first 3 visit(s) $0 then 50% after deductible copay, first 3 visit(s) $0 then 50% after deductible

SKU: 66699CO0070003 Categories: Alma, Arvada, Aurora, Bailey, Brighton, Broomfield, Buffalo Creek, Byers, Colorado, Commerce City, Como, Conifer, Denver, Dupont, Englewood, Evergreen, Fairplay, Fort Morgan, Golden, Grant, Guffey, Hartsel, Henderson, Hudson, Idledale, Indian Hills, Jefferson, Keenesburg, Kittredge, Littleton, Morrison, Pine, Sedalia, Shawnee, Strasburg, Thornton, Watkins, Westminster, Wheat Ridge, Wiggins

Description

Description

Health Care Plan Details

Network type	HMO
Deductible	$7,500 per person $7,500 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	first 3 visit(s) $0 then $50 copay after deductible
Specialist visit	first 3 visit(s) $0 then 50% after deductible copay, first 3 visit(s) $0 then 50% after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	first 3 visit(s) $0 then 50% after deductible copay, first 3 visit(s) $0 then 50% after deductible
Emergency room	50% after deductible
Ambulance	50% after deductible
Hospital stay (facility)	50% after deductible
Hospital stay (physician)	50% after deductible
Outpatient procedure (facility)	50% after deductible
Outpatient procedure (physician)	50% after deductible
Physical rehabilitation	50% after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay

50% after deductible

Pharmacy, Drugs, and Medication

Generic	$15 copay
Brand	$100 copay
Non-preferred Brand	$175 copay
Specialty	$350 copay

Lab Tests and Diagnostic Procedures

X-rays	50% after deductible
Imaging (CT/PET/MRI)	50% after deductible
Blood work	50% after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	first 3 visit(s) $0 then 50% after deductible copay, first 3 visit(s) $0 then 50% after deductible
Psychiatric hospital stay	50% after deductible

Health Plan Provider Information

Health Plan Benefits

https://d2ed110nmrd591.cloudfront.net/blobs/WZA6tgYzcEo7jLv661kw81Bq.pdf