Premier Bronze HSA – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$5,200 per person $5,200 per person
Out-of-pocket max	$8,050 per person $16,100 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$60 copay after deductible
Specialist visit	$100 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$60 copay after deductible
Emergency room	50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	$100 copay after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$3 copay after deductible
Brand	$150 copay after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	$60 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$60 copay after deductible
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://api.centene.com/SBC/2024/64004DE0090001-01.pdf
Drug and medication plan formulary	https://ambetterhealthofdelaware.com/resources/pharmacy-resources.html
Search doctor list	https://ambetterhealthofdelaware.com/findadoc