Bronze IND POS 8000, Bronze, NS, OON, POS, Dep29, Family Vision, Family Dental, WP – POS

Description

Health Care Plan Details

Network type	POS
Deductible	$8,500 per person $8,500 per person
Out-of-pocket max	$9,100 per person $18,200 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	50% coinsurance after deductible
Specialist visit	50% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	50% coinsurance after deductible
Emergency room	50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$15 copay after deductible
Brand	50% coinsurance after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	No data available

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	50% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	50% coinsurance after deductible
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits

https://shop.highmark.com/sales/#!/sbcs/wny