Bronze QHDHP PPO 6400/0/50 + Bronze + PPO + HSA Eligible – PPO
Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: $50 copay after deductible
Specialist visit: $85 copay after deductible
Urgent care visit: $100 copay after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $6,400 per person $6,400 per person |
| Out-of-pocket max | $7,450 per person $14,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $50 copay after deductible |
| Specialist visit | $85 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $100 copay after deductible |
| Emergency room | $400 copay after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | No charge after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $85 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | No charge after deductible |
Pharmacy, Drugs, and Medication
| Generic | No charge after deductible |
| Brand | No charge after deductible |
| Non-preferred Brand | No charge after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge after deductible |
| Imaging (CT/PET/MRI) | No charge after deductible |
| Blood work | $25 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay after deductible |
| Psychiatric hospital stay | No charge after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/hyLbUczKYUHhs5ukUYzZEYYM.pdf |
| Drug and medication plan formulary | https://www.healthcare.gov/sbc-glossary/#prescription-drug-coverage |
