Bronze PPO Standard Pathway – PPO
Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: $50 copay
Specialist visit: $70 copay after deductible
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $6,550 per person $6,550 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $50 copay |
| Specialist visit | $70 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | $450 copay after deductible |
| Ambulance | No charge 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 | 50% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible, up to $500 per script copay, 50% after deductible, up to $500 per script |
Lab Tests and Diagnostic Procedures
| X-rays | $40 copay after deductible |
| Imaging (CT/PET/MRI) | first 5 visit(s) $75 copay after deductible then $0 |
| Blood work | $20 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| 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/XnwnbudRdtyVEVb9GsR23n3k.pdf |
| Drug and medication plan formulary | https://www.anthem.com/ms/pharmacyinformation/home.html |
