Bronze Value 1814 (High Value Network Savings, Open Access) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$8,300 per person $8,300 per person
Out-of-pocket max	$8,700 per person $17,400 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$45 copay
Specialist visit	40% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	40% coinsurance after deductible
Emergency room	40% coinsurance after deductible
Ambulance	40% coinsurance after deductible
Hospital stay (facility)	40% coinsurance after deductible
Hospital stay (physician)	40% coinsurance after deductible
Outpatient procedure (facility)	40% coinsurance after deductible
Outpatient procedure (physician)	40% coinsurance after deductible
Physical rehabilitation	40% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$15 copay
Brand	35% coinsurance after deductible
Non-preferred Brand	45% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	40% coinsurance after deductible
Imaging (CT/PET/MRI)	40% coinsurance after deductible
Blood work	40% coinsurance after deductible

Mental and Psychiatric Health Care

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

Health Plan Provider Information

Health Plan Benefits	https://hf.org/2024_sbc_1814.pdf
Drug and medication plan formulary	https://hf.org/MP_formulary_2024
Search doctor list	https://hf.org/MP_directory_2024