Blue Cross® Select HMO Bronze Saver HSA – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$7,950 per person $7,950 per person
Out-of-pocket max	$7,950 per person $15,900 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	No charge after deductible
Specialist visit	No charge after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	No charge after deductible
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	No charge after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	No charge after deductible

Pharmacy, Drugs, and Medication

Generic	No charge after deductible
Brand	No charge after deductible
Non-preferred Brand	No charge after deductible
Specialty	No charge after deductible

Lab Tests and Diagnostic Procedures

X-rays	No charge after deductible
Imaging (CT/PET/MRI)	No charge after deductible
Blood work	No charge after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	No charge after deductible
Psychiatric hospital stay	No charge after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsm.com/amslibs/content/dam/public/marketplace/2024-individual/sbc/select-bronze-saver-sbc.pdf
Drug and medication plan formulary	https://www.bcbsm.com/2024-select-hmo-druglist
Search doctor list	https://www.bcbsm.com/marketplace/select-hmo/