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

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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