Bronze 4: HMO Aetna network of doctors & hospitals – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $15 copay
Specialist visit: $100 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,400 per person $18,800 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $100 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $2,200 copay |
| Ambulance | $2,200 copay |
| Hospital stay (facility) | first 3 day(s) $2,500 per day then $0 copay |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $1,000 copay |
| Outpatient procedure (physician) | $500 copay |
| Physical rehabilitation | $80 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 3 day(s) $2,500 per day then $0 copay |
Pharmacy, Drugs, and Medication
| Generic | $40 per script copay |
| Brand | 40% after deductible |
| Non-preferred Brand | 45% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $75 copay |
| Imaging (CT/PET/MRI) | $750 copay |
| Blood work | $50 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | first 3 day(s) $2,500 per day then $0 copay |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/QnWSXcQjyGTmP9VznD2CW4Nk.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=6177461753 |
