Bronze Elite + PCP Saver Plus | MercyOne – EPO

Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: $40 copay
Specialist visit: $125 copay
Urgent care visit: $125 copay

SKU: 45819IA0010005 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

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 $125 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/IA/sbc/2024_45819IA001000501.pdf
Drug and medication plan formulary https://www.hioscar.com/search-documents/drug-formularies/
Search doctor list https://www.hioscar.com/search/?networkId=041&year=2024