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 |