Bronze Elite PCP Saver – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $40 copay
Specialist visit: $125 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $100 per person $100 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $125 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | $1,500 copay |
| Ambulance | $1,500 copay |
| Hospital stay (facility) | 50% after deductible |
| Hospital stay (physician) | 50% after deductible |
| Outpatient procedure (facility) | $1,200 copay |
| Outpatient procedure (physician) | $350 copay |
| Physical rehabilitation | $125 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 50% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | $70 copay after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $125 copay |
| Imaging (CT/PET/MRI) | $750 copay |
| Blood work | $25 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $125 copay |
| Psychiatric hospital stay | 50% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/mVkH8RdY5MaogjZHXDR7nP6B.pdf |
