Bronze Classic – HMO

Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $80 copay
Specialist visit: $100 copay
Urgent care visit: $150 copay

SKU: 98517PA0010003 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type HMO
Deductible $6,500 per person $6,500 per person
Out-of-pocket max $8,900 per person $17,800 per family
Metal tier Expanded Bronze

Visit Copay

Primary care visit $80 copay
Specialist visit $100 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $150 copay
Emergency room 50% after deductible
Ambulance 50% after deductible
Hospital stay (facility) 50% after deductible
Hospital stay (physician) 50% after deductible
Outpatient procedure (facility) $1,200 copay after deductible
Outpatient procedure (physician) $350 copay after deductible
Physical rehabilitation $100 copay

Maternitowny and Pregnancy

Labor, delivery, hospital stay 50% after deductible

Pharmacy, Drugs, and Medication

Generic $3 copay
Brand $250 copay after deductible
Non-preferred Brand 50% after deductible
Specialty 50% after deductible

Lab Tests and Diagnostic Procedures

X-rays $150 copay
Imaging (CT/PET/MRI) 50% after deductible
Blood work $10 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services $80 copay
Psychiatric hospital stay 50% after deductible

Health Plan Provider Information

Health Plan Benefits https://d2ed110nmrd591.cloudfront.net/blobs/ZRgbvbw7bu8xY1CTpCAJMWV7.pdf