Innovation Health – Aetna Bronze 4: HMO – HMO

Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $15 copay
Specialist visit: $100 copay
Urgent care visit: $50 copay

Description

Health Care Plan Details

Network type HMO
Deductible $0 per person $0 per person
Out-of-pocket max $9,400 per person $18,800 per family
Metal tier Expanded Bronze

Visit Copay

Primary care visit $15 copay
Specialist visit $100 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $50 copay
Emergency room $2,200 copay
Ambulance $2,200 copay
Hospital stay (facility) first 3 day(s) $2,500 per day then $0 copay
Hospital stay (physician) No charge
Outpatient procedure (facility) $1,000 copay
Outpatient procedure (physician) $500 copay
Physical rehabilitation $80 copay

Maternitowny and Pregnancy

Labor, delivery, hospital stay first 3 day(s) $2,500 per day then $0 copay

Pharmacy, Drugs, and Medication

Generic $40 per script copay
Brand 40% after deductible
Non-preferred Brand 45% after deductible
Specialty 50% after deductible

Lab Tests and Diagnostic Procedures

X-rays $75 copay
Imaging (CT/PET/MRI) $750 copay
Blood work $50 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $15 copay
Psychiatric hospital stay first 3 day(s) $2,500 per day then $0 copay

Health Plan Provider Information

Health Plan Benefits https://d2ed110nmrd591.cloudfront.net/blobs/hnyzQm6uD9cofJPviX331rFq.pdf
Drug and medication plan formulary https://client.formularynavigator.com/Search.aspx?siteCode=6179884039