Bronze 60 HMO – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $60 copay after deductible
Specialist visit: $95 copay after deductible
Urgent care visit: $60 copay after deductible
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $6,300 per person $6,300 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $60 copay after deductible |
| Specialist visit | $95 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay after deductible |
| Emergency room | 40% coinsurance after deductible |
| Ambulance | 40% coinsurance after deductible |
| Hospital stay (facility) | 40% coinsurance after deductible |
| Hospital stay (physician) | 40% coinsurance after deductible |
| Outpatient procedure (facility) | 40% after deductible |
| Outpatient procedure (physician) | 40% coinsurance after deductible |
| Physical rehabilitation | $60 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 40% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $17 copay after deductible |
| Brand | 40% coinsurance after deductible |
| Non-preferred Brand | 40% coinsurance after deductible |
| Specialty | 40% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 40% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 40% coinsurance after deductible |
| Blood work | $40 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $60 copay |
| Psychiatric hospital stay | 40% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/mbseHSCsZnSQkeRyDf1KvHpH.pdf |
