Bronze Select 6800 w/ GYM – Limited Service Area – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $35 copay
Specialist visit: 40% after deductible
Urgent care visit: $35 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $6,800 per person $6,800 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | 40% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $35 copay |
| Emergency room | 40% after deductible |
| Ambulance | 40% after deductible |
| Hospital stay (facility) | 50% coinsurance |
| Hospital stay (physician) | 40% after deductible |
| Outpatient procedure (facility) | 40% after deductible |
| Outpatient procedure (physician) | 40% after deductible |
| Physical rehabilitation | $35 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 50% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | 40% after deductible |
| Brand | 40% after deductible |
| Non-preferred Brand | 40% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 40% after deductible |
| Imaging (CT/PET/MRI) | 40% after deductible |
| Blood work | 40% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | No charge |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/Xws4mjKB2BvxUi997QodPM9x.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=0324498195 |
