Standard Expanded Bronze + Vision + Adult Dental – EPO
Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: $50 copay
Specialist visit: $100 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $7,500 per person $7,500 per person |
| Out-of-pocket max | $9,400 per person $18,800 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $50 copay |
| Specialist visit | $100 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| 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 | $50 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 copay |
| Brand | $50 copay after deductible |
| Non-preferred Brand | $100 copay after deductible |
| Specialty | $150 copay after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 50% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 50% coinsurance after deductible |
| Blood work | 50% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | 50% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://api.centene.com/SBC/2024/90787LA0020009-01.pdf |
| Drug and medication plan formulary | https://ambetter.louisianahealthconnect.com/resources/pharmacy-resources.html |
| Search doctor list | https://ambetter.louisianahealthconnect.com/findadoc |
