Connect Bronze Expanded – PPO
Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $110 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $9,100 per person $9,100 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $80 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $110 copay |
| Emergency room | No charge after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | No charge after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $80 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | No charge after deductible |
Pharmacy, Drugs, and Medication
| Generic | No charge after deductible |
| Brand | No charge after deductible |
| Non-preferred Brand | No charge after deductible |
| Specialty | No charge after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge after deductible |
| Imaging (CT/PET/MRI) | No charge after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | No charge after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://mountainhealth.coop/wp-content/uploads/plans/2024/2024_IND_MT_CONNECT_BRONZE_EXPANDED_SBC.pdf |
| Drug and medication plan formulary | https://cbg.adaptiverx.com/webSearch/index?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B68BF3A93E5C825DF42 |
| Search doctor list | https://mountainhealth.coop/find-a-doctor/ |
