Clear Choice PPO Bronze 7500 – PPO
Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: $45 copay
Specialist visit: $80 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | See brochure See brochure |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $45 copay |
| Specialist visit | $80 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| 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 | $45 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 50% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $30 per script copay |
| Brand | $50 per script copay |
| Non-preferred Brand | $100 per script after deductible copay |
| Specialty | $100 per script after deductible copay |
Lab Tests and Diagnostic Procedures
| X-rays | 50% after deductible |
| Imaging (CT/PET/MRI) | 50% after deductible |
| Blood work | 50% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 1 visit(s) $0 then $45 copay |
| Psychiatric hospital stay | 50% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/8bJgUtG5Nxyd5JJmsJACByMe.pdf |
| Drug and medication plan formulary | https://www.harvardpilgrim.org/2024Value5T |