HSA Bronze $6,150 – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $30 copay after deductible
Specialist visit: $40 copay after deductible
Urgent care visit: $60 copay after deductible
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $6,150 per person $6,150 per person |
| Out-of-pocket max | $7,200 per person $14,400 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $30 copay after deductible |
| Specialist visit | $40 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay after deductible |
| Emergency room | $300 copay after deductible |
| Ambulance | $40 copay after deductible |
| Hospital stay (facility) | first 5 day(s) $500 then $0 copay after deductible |
| Hospital stay (physician) | $40 copay after deductible |
| Outpatient procedure (facility) | $450 copay after deductible |
| Outpatient procedure (physician) | $450 copay after deductible |
| Physical rehabilitation | $40 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $500 per day after deductible, up to $2,250 copay |
Pharmacy, Drugs, and Medication
| Generic | $10 per script after deductible copay |
| Brand | $50 per script after deductible copay |
| Non-preferred Brand | $70 per script after deductible copay |
| Specialty | $100 per script after deductible copay |
Lab Tests and Diagnostic Procedures
| X-rays | $55 copay after deductible |
| Imaging (CT/PET/MRI) | $250 copay after deductible |
| Blood work | $25 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay after deductible |
| Psychiatric hospital stay | first 5 day(s) $500 then $0 copay after deductible |
