Bronze Classic PCP Saver Plus – HMO

Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: No charge
Specialist visit: 50% after deductible
Urgent care visit: 50% after deductible

SKU: 98517PA0010021 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type HMO
Deductible $8,500 per person $8,500 per person
Out-of-pocket max $9,100 per person $18,200 per family
Metal tier Expanded Bronze

Visit Copay

Primary care visit No charge
Specialist visit 50% after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care 50% after deductible
Emergency room 50% after deductible
Ambulance 50% after deductible
Hospital stay (facility) 50% after deductible
Hospital stay (physician) 50% after deductible
Outpatient procedure (facility) 50% after deductible
Outpatient procedure (physician) 50% after deductible
Physical rehabilitation 50% after deductible

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

Mental and Psychiatric Health Care

Mental Health outpatient services 50% after deductible
Psychiatric hospital stay 50% after deductible

Health Plan Provider Information

Health Plan Benefits https://d2ed110nmrd591.cloudfront.net/blobs/LEaQFGqBNeix4sPwgaikZxQE.pdf