Bronze Essential 8500 – EPO
Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: first 4 visit(s) $60 then 10% after deductible copay, first 4 visit(s) $60 then 10% after deductible
Specialist visit: first 4 visit(s) $60 then 10% after deductible copay, first 4 visit(s) $60 then 10% after deductible
Urgent care visit: first 4 visit(s) $60 then 10% after deductible copay, first 4 visit(s) $60 then 10% after deductible
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $8,500 per person $8,500 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | first 4 visit(s) $60 then 10% after deductible copay, first 4 visit(s) $60 then 10% after deductible |
| Specialist visit | first 4 visit(s) $60 then 10% after deductible copay, first 4 visit(s) $60 then 10% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | first 4 visit(s) $60 then 10% after deductible copay, first 4 visit(s) $60 then 10% after deductible |
| Emergency room | 10% after deductible |
| Ambulance | 10% after deductible |
| Hospital stay (facility) | 10% after deductible |
| Hospital stay (physician) | 10% after deductible |
| Outpatient procedure (facility) | 10% after deductible |
| Outpatient procedure (physician) | 10% after deductible |
| Physical rehabilitation | 10% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 10% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | 30% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 10% after deductible |
| Imaging (CT/PET/MRI) | 10% after deductible |
| Blood work | 10% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 10% after deductible |
| Psychiatric hospital stay | 10% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/UJj58j5BTH5hSu4cS3RWn6wp.pdf |
