Bronze Elite + PCP Saver Plus – 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) | first 2 day(s) $3,000 per day then $0 copay |
| Hospital stay (physician) | $350 copay |
| Outpatient procedure (facility) | $1,200 copay |
| Outpatient procedure (physician) | $350 copay |
| Physical rehabilitation | $125 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 2 day(s) $3,000 per day then $0 copay |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | $100 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 | first 2 day(s) $3,000 per day then $0 copay |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/Qe9o8TRK711KJU1XiTk1AwPh.pdf |
