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) | $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/MO/sbc/2024_69512MO001000501.pdf |
Drug and medication plan formulary | https://www.hioscar.com/search-documents/drug-formularies/ |
Search doctor list | https://www.hioscar.com/search/?networkId=029&year=2024 |