HMO Bronze $0 Medical Deductible – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $35 copay
Specialist visit: $200 copay
Urgent care visit: $200 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | Success
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| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $200 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $200 copay |
| Emergency room | $3,000 copay |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | $1500 copay per Day |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | $200 copay |
| Outpatient procedure (physician) | $200 copay |
| Physical rehabilitation | $200 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $35 copay |
| Brand | $125 copay |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 50% coinsurance |
| Imaging (CT/PET/MRI) | 50% coinsurance |
| Blood work | 50% coinsurance |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay |
| Psychiatric hospital stay | $1500 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://www.aspirushealthplan.com/group-individual/files/sbcs/2024/86584WI0010016-01.pdf |
| Drug and medication plan formulary | https://www.aspirushealthplan.com/group-individual/Aspirus_Drug_Formulary/AspirusDrugFormulary2023.PDF |
| Search doctor list | https://p1.aspirushealthplan.com/find-a-doctor |
