BridgeSpan Standard Bronze Plan – EPO

Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: $50 copay
Specialist visit: $150 copay
Urgent care visit: $100 copay

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Description

Health Care Plan Details

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

Visit Copay

Primary care visit $50 copay
Specialist visit $150 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $100 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 $50 copay

Maternitowny and Pregnancy

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

Pharmacy, Drugs, and Medication

Generic $25 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 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 $50 copay
Psychiatric hospital stay No charge after deductible

Health Plan Provider Information

Health Plan Benefits https://bridgespanhealth.com/go/2024/SBC/OR/StandardBronzeRVEx.pdf
Drug and medication plan formulary https://bridgespanhealth.com/go/2024/OR/4tier
Search doctor list https://bridgespanhealth.com/go/OR/RealValue