IFP ON Bronze Plus HMO – HMO

Network type: HMO
Coverage tier: Bronze
Primary care visit: $55 copay
Specialist visit: $100 copay
Urgent care visit: $50 copay

Description

Health Care Plan Details

Network type HMO
Deductible $4,725 per person $4,725 per person
Out-of-pocket max $9,450 per person $18,900 per family
Metal tier Bronze

Visit Copay

Primary care visit $55 copay
Specialist visit $100 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $50 copay
Emergency room 50% after deductible
Ambulance 50% after deductible
Hospital stay (facility) 50% after deductible
Hospital stay (physician) 50% after deductible
Outpatient procedure (facility) 50% after deductible
Outpatient procedure (physician) 50% after deductible
Physical rehabilitation $100 copay

Maternitowny and Pregnancy

Labor, delivery, hospital stay 50% after deductible

Pharmacy, Drugs, and Medication

Generic $20 copay
Brand 50% after deductible
Non-preferred Brand 50% after deductible
Specialty 50% after deductible

Lab Tests and Diagnostic Procedures

X-rays 50% after deductible
Imaging (CT/PET/MRI) 50% after deductible
Blood work 50% after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services 50% after deductible
Psychiatric hospital stay 50% after deductible

Health Plan Provider Information