Bronze $6,100 – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $40 copay
Specialist visit: $50 copay
Urgent care visit: $70 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $6,100 per person $6,100 per person |
| Out-of-pocket max | $9,400 per person $18,800 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $70 copay |
| Emergency room | 40% after deductible |
| Ambulance | $50 copay after deductible |
| Hospital stay (facility) | 40% after deductible |
| Hospital stay (physician) | 40% after deductible |
| Outpatient procedure (facility) | $450 copay after deductible |
| Outpatient procedure (physician) | $450 copay after deductible |
| Physical rehabilitation | $50 copay after deductible |
Maternitowny and Pregnancy
Pharmacy, Drugs, and Medication
| Generic | $20 per script copay |
| Brand | $50 per script after deductible copay |
| Non-preferred Brand | $70 per script after deductible copay |
| Specialty | $100 per script after deductible copay |
Lab Tests and Diagnostic Procedures
| X-rays | $55 copay after deductible |
| Imaging (CT/PET/MRI) | $250 copay after deductible |
| Blood work | $25 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $100 copay after deductible |
| Psychiatric hospital stay | 40% after deductible |
