Bronze Elite + PCP Saver Plus (Choice) – EPO
Network type: EPO
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 | EPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,450 per person $18,900 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 | $2,000 copay |
| Ambulance | $2,000 copay |
| Hospital stay (facility) | $3000 copay per Day |
| Hospital stay (physician) | $350 copay |
| Outpatient procedure (facility) | $1,200 copay |
| Outpatient procedure (physician) | $350 copay |
| Physical rehabilitation | $125 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $3,000 copay |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | $100 copay after deductible |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance 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 | $3000 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://d3ul0st9g52g6o.cloudfront.net/2024/TX/sbc/2024_20069TX020000501.pdf |
| Drug and medication plan formulary | https://www.hioscar.com/search-documents/drug-formularies/ |
| Search doctor list | https://www.hioscar.com/search/?networkId=058&year=2024 |
