IDID Southwest Bronze HSA 6250 – POS
Network type: POS
Coverage tier: Expanded Bronze
Primary care visit: 20% after deductible
Specialist visit: 20% after deductible
Urgent care visit: 20% after deductible
Description
Health Care Plan Details
| Network type | POS |
| Deductible | $6,250 per person $6,250 per person |
| Out-of-pocket max | $7,500 per person $15,000 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | 20% after deductible |
| Specialist visit | 20% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 20% after deductible |
| Emergency room | $350 copay after deductible |
| Ambulance | 20% after deductible |
| Hospital stay (facility) | 20% after deductible |
| Hospital stay (physician) | 20% after deductible |
| Outpatient procedure (facility) | 20% after deductible |
| Outpatient procedure (physician) | 20% after deductible |
| Physical rehabilitation | 20% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 20% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay after deductible |
| Brand | $30 copay after deductible |
| Non-preferred Brand | $50 copay after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 20% after deductible |
| Imaging (CT/PET/MRI) | $250 plus 20% after deductible copay, $250 plus 20% after deductible |
| Blood work | 20% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 20% after deductible |
| Psychiatric hospital stay | 20% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/yFL8MoTSqmBjB3BTEbzStcUJ.pdf |
