
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 |