Bronze Simple HSA – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $40 copay after deductible
Specialist visit: $90 copay after deductible
Urgent care visit: $75 copay after deductible
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 | $90 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay after deductible |
| Emergency room | 50% after deductible |
| Ambulance | 50% after deductible |
| Hospital stay (facility) | 50% after deductible |
| Hospital stay (physician) | 50% after deductible |
| Outpatient procedure (facility) | 50% after deductible |
| Outpatient procedure (physician) | 50% after deductible |
| Physical rehabilitation | $90 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 50% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $3 copay after deductible |
| Brand | $200 copay after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 50% after deductible |
| Imaging (CT/PET/MRI) | 50% 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% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/QnsThc9aAyyH8iE62ssJ7w7H.pdf |
