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(2025) Bronze MI04 HMO
Health Insurance Plan Details (2025 Plan)
by Sutter Health Plan
Monthly Premium
HMO
$ubsidy
Bronze
- Deductible
- $5,800 /yr
- Max Out-of-Pocket
- $8,850 /yr
Details
| Deductible (per individual) | $5,800 /yr |
| Deductible (per family) | $11,600 /yr |
| Max Out-of-Pocket (per individual) | $8,850 /yr |
| Max Out-of-Pocket (per family) | $17,700 /yr |
| Drug Deductible (per individual) | |
| Drug Deductible (per family) | |
| Drug Max Out-of-Pocket (per individual) | |
| Drug Max Out-of-Pocket (per family) | |
| Plan Type | HMO |
| Includes Child Dental? | Yes |
| Includes Adult Dental? | No |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | $60 Copay |
| Specialist Visit | $95 Copay after deductible |
| Emergency Room | 40.00% Coinsurance after deductible |
| Inpatient Facility | 40.00% Coinsurance after deductible |
| Inpatient Physician | 40.00% Coinsurance after deductible |
| Generic Drugs | $19 Copay |
| Preferred Brand Drugs | 40.00% Coinsurance after deductible |
| Non-preferred Brand Drugs | 40.00% Coinsurance after deductible |
| Specialty Drugs | 40.00% Coinsurance after deductible |
Plan Documents
| Summary of Benefits and Coverage | SBC doc |
| Provider Directory | Doctor lookup |
| Drug Formulary List | n/a |
* Figures shown are only for in-network medical costs
** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible
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