Bronze Classic PCP Saver (Select) – HMO

Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $30 copay
Specialist visit: $90 copay after deductible
Urgent care visit: $100 copay

Description

Health Care Plan Details

Network type HMO
Deductible $7,750 per person $7,750 per person
Out-of-pocket max $9,100 per person $18,200 per family
Metal tier Expanded Bronze

Visit Copay

Primary care visit $30 copay
Specialist visit $90 copay after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $100 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) $1200 copay after deductible
Outpatient procedure (physician) $350 copay 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 $200 copay
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 $10 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services $90 copay after deductible
Psychiatric hospital stay 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://d3ul0st9g52g6o.cloudfront.net/2024/OH/sbc/2024_29341OH010000201.pdf
Drug and medication plan formulary https://www.hioscar.com/search-documents/drug-formularies/
Search doctor list https://www.hioscar.com/search/?networkId=020&year=2024