Value Bronze Standard POS [{LCSR)] – POS

Network type: POS
Coverage tier: Expanded Bronze
Primary care visit: $50 copay
Specialist visit: $70 copay after deductible
Urgent care visit: $75 copay

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Description

Health Care Plan Details

Network type POS
Deductible $6,550 per person $6,550 per person
Out-of-pocket max $9,100 per person $18,200 per family
Metal tier Expanded Bronze

Visit Copay

Primary care visit $50 copay
Specialist visit $70 copay after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $75 copay
Emergency room $450 copay after deductible
Ambulance No charge after deductible
Hospital stay (facility) first 2 day(s) $500 per day then $0 copay after deductible
Hospital stay (physician) first 2 day(s) $500 per day then $0 copay after deductible
Outpatient procedure (facility) $500 copay after deductible
Outpatient procedure (physician) $500 copay after deductible
Physical rehabilitation $30 copay after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay first 2 day(s) $500 per day then $0 copay after deductible

Pharmacy, Drugs, and Medication

Generic $20 per script copay
Brand 50% after deductible
Non-preferred Brand 50% after deductible
Specialty 50% after deductible, up to $500 per script copay, 50% after deductible, up to $500 per script

Lab Tests and Diagnostic Procedures

X-rays $40 per procedure after deductible copay
Imaging (CT/PET/MRI) $75 per procedure, up to $375 copay
Blood work $20 per procedure copay

Mental and Psychiatric Health Care

Mental Health outpatient services $50 copay
Psychiatric hospital stay first 2 day(s) $500 per day then $0 copay after deductible

Health Plan Provider Information