Standard High Bronze HSA – Flex – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $60 copay after deductible
Specialist visit: $90 copay after deductible
Urgent care visit: $90 copay after deductible
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $3,600 per person $3,600 per person |
| Out-of-pocket max | $8,000 per person $16,000 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $60 copay after deductible |
| Specialist visit | $90 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $90 copay after deductible |
| Emergency room | $875 copay after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | $1,500 copay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $500 copay after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $90 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $1,500 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $30 copay after deductible |
| Brand | $120 copay after deductible |
| Non-preferred Brand | $200 copay after deductible |
| Specialty | $200 copay after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $135 copay after deductible |
| Imaging (CT/PET/MRI) | $750 copay after deductible |
| Blood work | $55 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $60 copay after deductible |
| Psychiatric hospital stay | $1,500 copay after deductible |
