Select Bronze No Medical Ded/9450 MOOP – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $45 copay
Specialist visit: $160 copay
Urgent care visit: $45 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $45 copay |
| Specialist visit | $160 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $45 copay |
| Emergency room | $1,500 copay |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | 50% coinsurance |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | $1,500 copay |
| Outpatient procedure (physician) | 50% coinsurance |
| Physical rehabilitation | 50% coinsurance |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $35 copay |
| Brand | $175 copay |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $55 copay |
| Imaging (CT/PET/MRI) | $1,000 copay |
| Blood work | $55 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $45 copay |
| Psychiatric hospital stay | 50% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://planfinder.ghcscw.com/sbc/2412427.pdf |
| Drug and medication plan formulary | https://ghcscw.com/members/understanding-your-pharmacy-benefits/ |
| Search doctor list | https://providersearch.ghcscw.com/public/#/ |
