SummaCare Bronze 9450 with 3 Free PCP Visits – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $30 copay
Specialist visit: No charge after deductible
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $9,450 per person $9,450 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | No charge after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | No charge after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | No charge after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | No charge after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | No charge after deductible |
Pharmacy, Drugs, and Medication
| Generic | No charge after deductible |
| Brand | No charge after deductible |
| Non-preferred Brand | No charge after deductible |
| Specialty | No charge after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge after deductible |
| Imaging (CT/PET/MRI) | No charge after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | No charge after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.summacare.com/-/media/Project/SummaCare/Website/Document-Library/SBCs/IFP/2024/2024-SBC-SummaCare-Bronze-9450-EHB-Only.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=3823697592 |
| Search doctor list | https://www.summacare.com/scconnect |
