Bronze Classic PCP Saver Plus | MercyOne – EPO

Description

Health Care Plan Details

Network type	EPO
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% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$75 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	50% coinsurance after deductible

Maternitowny and Pregnancy

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

Pharmacy, Drugs, and Medication

Generic	$3 copay
Brand	$500 copay 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	50% coinsurance after deductible
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://d3ul0st9g52g6o.cloudfront.net/2024/IA/sbc/2024_45819IA001002101.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