Bronze Classic 4700 – EPO

Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: $70 copay
Specialist visit: $125 copay
Urgent care visit: $80 copay

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Description

Health Care Plan Details

Network type EPO
Deductible $4,700 per person $4,700 per person
Out-of-pocket max $9,100 per person $18,200 per family
Metal tier Expanded Bronze

Visit Copay

Primary care visit $70 copay
Specialist visit $125 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $80 copay
Emergency room 50% coinsurance after deductible
Ambulance 50% coinsurance after deductible
Hospital stay (facility) 50% coinsurance after deductible
Hospital stay (physician) 50% coinsurance after deductible
Outpatient procedure (facility) 50% coinsurance after deductible
Outpatient procedure (physician) 50% coinsurance after deductible
Physical rehabilitation $125 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $3 copay
Brand 50% coinsurance after deductible
Non-preferred Brand 50% coinsurance after deductible
Specialty 50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays 50% coinsurance after deductible
Imaging (CT/PET/MRI) 50% coinsurance after deductible
Blood work $25 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $70 copay
Psychiatric hospital stay 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://d3ul0st9g52g6o.cloudfront.net/2024/IA/sbc/2024_45819IA001006001.pdf
Drug and medication plan formulary https://www.hioscar.com/search-documents/drug-formularies/
Search doctor list https://www.hioscar.com/search/?networkId=041&year=2024