Signature Prestige Bronze Copay + Dental + Vision – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $55 copay
Specialist visit: $150 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $55 copay |
| Specialist visit | $150 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | An urgent care center can be a convenient option if you have a non-life-threatening injury and your doctor is not available. |
| Ambulance | $150 copay |
| Hospital stay (facility) | $1500 copay per Day |
| Hospital stay (physician) | $150 copay |
| Outpatient procedure (facility) | $150 copay |
| Outpatient procedure (physician) | $150 copay |
| Physical rehabilitation | $75 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $1,500 copay |
Pharmacy, Drugs, and Medication
| Generic | $30 copay |
| Brand | $160 copay |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 40% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $150 copay |
| Imaging (CT/PET/MRI) | $500 copay |
| Blood work | $75 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $55 copay |
| Psychiatric hospital stay | $1500 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://networkhealth.com/__assets/pdf/individual-benefits-2024/signaturebronzecopay.pdf |
| Drug and medication plan formulary | https://www.networkhealth.com/__assets/pdf/pharmacy-drug-lists/2024individualdruglist5tier.pdf |
| Search doctor list | https://www.networkhealth.com/find-a-doctor-prestige |
