Bronze Simple HSA – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$5,000 per person $5,000 per person
Out-of-pocket max	$7,450 per person $14,900 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$40 copay after deductible
Specialist visit	$80 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$100 copay after deductible
Emergency room	50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	$80 copay after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$3 copay after deductible
Brand	$200 copay after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	$10 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$40 copay after deductible
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://d3ul0st9g52g6o.cloudfront.net/2024/NC/sbc/2024_69803NC001001401.pdf
Drug and medication plan formulary	https://www.hioscar.com/search-documents/drug-formularies/
Search doctor list	https://www.hioscar.com/search/?networkId=043&year=2024