Bronze Classic, Bronze, ST, INN, Circle Wellness Rewards DP FP Dep 29 – EPO
Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: first 3 visit(s) $50 then $50 copay after deductible
Specialist visit: first 3 visit(s) $75 then $75 copay after deductible
Urgent care visit: first 3 visit(s) $75 then $75 copay after deductible
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $4,600 per person $4,600 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | first 3 visit(s) $50 then $50 copay after deductible |
| Specialist visit | first 3 visit(s) $75 then $75 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | first 3 visit(s) $75 then $75 copay after deductible |
| Emergency room | $500 copay after deductible |
| Ambulance | $300 copay after deductible |
| Hospital stay (facility) | $1,500 copay after deductible |
| Hospital stay (physician) | $150 copay after deductible |
| Outpatient procedure (facility) | $150 copay after deductible |
| Outpatient procedure (physician) | $150 copay after deductible |
| Physical rehabilitation | $50 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $1,500 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay after deductible |
| Brand | $35 copay after deductible |
| Non-preferred Brand | $70 copay after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $75 copay after deductible |
| Imaging (CT/PET/MRI) | $175 copay after deductible |
| Blood work | $50 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 3 visit(s) $50 then $50 copay after deductible |
| Psychiatric hospital stay | $1,500 copay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/bX9CmUmurPgVAhBDvzWbvH4y.pdf |
