Bronze PPO Pathway with Added Dental and Vision Benefits – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$7,000 per person $7,000 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$70 copay
Specialist visit	$90 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$100 copay after deductible
Emergency room	$500 copay after deductible
Ambulance	40% after deductible
Hospital stay (facility)	first 2 day(s) $500 per day then $0 copay after deductible
Hospital stay (physician)	No charge after deductible
Outpatient procedure (facility)	$500 copay after deductible
Outpatient procedure (physician)	No charge after deductible
Physical rehabilitation	$30 copay after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay

first 2 day(s) $500 per day then $0 copay after deductible

Pharmacy, Drugs, and Medication

Generic	$20 per script copay
Brand	$75 per script copay
Non-preferred Brand	50%, up to $500 per script copay, 50%, up to $500 per script coinsurance
Specialty	50% after deductible, up to $1,000 per script copay, 50% after deductible, up to $1,000 per script

Lab Tests and Diagnostic Procedures

X-rays	No charge after deductible
Imaging (CT/PET/MRI)	first 5 visit(s) $75 copay after deductible then $0
Blood work	$50 copay

Mental and Psychiatric Health Care

Mental Health outpatient services	$90 copay after deductible
Psychiatric hospital stay	first 2 day(s) $500 per day then $0 copay after deductible

Health Plan Provider Information

Health Plan Benefits	https://d2ed110nmrd591.cloudfront.net/blobs/KVRUZHgzvGQncXxaDSFzrLpk.pdf
Drug and medication plan formulary	https://www.anthem.com/ms/pharmacyinformation/home.html