Bronze PPO Standard Pathway for HSA – PPO
Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: 20% after deductible
Specialist visit: 20% after deductible
Urgent care visit: 20% after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $6,500 per person $6,500 per person |
| Out-of-pocket max | $7,225 per person $14,450 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | 20% after deductible |
| Specialist visit | 20% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 20% after deductible |
| Emergency room | 20% after deductible |
| Ambulance | 20% after deductible |
| Hospital stay (facility) | 20% after deductible |
| Hospital stay (physician) | 20% after deductible |
| Outpatient procedure (facility) | 20% after deductible |
| Outpatient procedure (physician) | 20% after deductible |
| Physical rehabilitation | 20% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 20% after deductible |
Pharmacy, Drugs, and Medication
| Generic | 20% after deductible |
| Brand | 25% after deductible |
| Non-preferred Brand | 30% after deductible |
| Specialty | 30% after deductible, up to $500 per script copay, 30% after deductible, up to $500 per script |
Lab Tests and Diagnostic Procedures
| X-rays | 20% after deductible |
| Imaging (CT/PET/MRI) | 20% after deductible |
| Blood work | 20% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 20% after deductible |
| Psychiatric hospital stay | 20% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/hZTJc52cFMefo8DaBaVHMs2L.pdf |
| Drug and medication plan formulary | https://www.anthem.com/ms/pharmacyinformation/home.html |
