Anthem Bronze Mountain Enhanced HMO 5650 Rx Copay $0 Select Drugs – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: first 2 visit(s) $50 then 40% after deductible copay, first 2 visit(s) $50 then 40% after deductible
Specialist visit: 40% after deductible
Urgent care visit: first 2 visit(s) $75 then $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $5,650 per person $5,650 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | first 2 visit(s) $50 then 40% after deductible copay, first 2 visit(s) $50 then 40% after deductible |
| Specialist visit | 40% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | first 2 visit(s) $75 then $75 copay |
| Emergency room | $300 plus 40% after deductible copay, $300 plus 40% after deductible |
| Ambulance | 50% after deductible |
| Hospital stay (facility) | $1,000 plus 40% after deductible copay, $1,000 plus 40% after deductible |
| Hospital stay (physician) | 40% after deductible |
| Outpatient procedure (facility) | 40% after deductible |
| Outpatient procedure (physician) | 40% after deductible |
| Physical rehabilitation | $50 plus 40% after deductible copay, $50 plus 40% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $1,000 plus 40% after deductible copay, $1,000 plus 40% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $30 copay |
| Brand | $75 copay |
| Non-preferred Brand | $150 copay |
| Specialty | $650 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 40% after deductible |
| Imaging (CT/PET/MRI) | $250 plus 40% after deductible copay, $250 plus 40% after deductible |
| Blood work | 40% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 40% after deductible |
| Psychiatric hospital stay | $1,000 plus 40% after deductible copay, $1,000 plus 40% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/CGiCEConCW4tpVdMF3da6j8D.pdf |
