Bronze 60 HMO – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$6,300 per person $6,300 per person
Out-of-pocket max	$8,200 per person $16,400 per family
Metal tier	Bronze

Visit Copay

Primary care visit	First 3 visits at $65 copay before deductible
Specialist visit	$95 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$65 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% coinsurance after deductible
Outpatient procedure (physician)	40% coinsurance after deductible
Physical rehabilitation	$65 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$18 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	$65 copay before deductible
Psychiatric hospital stay	40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://apply.coveredca.com/hix/download/document?documentId=ptacphoCDlku0_r5_Vcz0VFiyA2QCi97Xmqt0prTD_YBF-r_SChDImmbtSWseja71meIFCRVhRBjh6S-vWKpAQ
Drug and medication plan formulary	http://www.lacare.org/members/welcome-la-care/member-documents/la-care-covered
Search doctor list	http://www.lacare.org/health-plans/la-care-covered/find-provider/find-doctor-or-hospital