Choice Bronze Standard POS HSA

Health Insurance Plan Details (2024 Plan)

by ConnectiCare Benefits, Inc.

Monthly Premium

POS
$ubsidy
HSA
Bronze
Deductible
$6,500 /yr
Max Out-of-Pocket
$7,225 /yr

Details

Deductible (per individual) $6,500 /yr
Deductible (per family) $13,000 /yr
Max Out-of-Pocket (per individual) $7,225 /yr
Max Out-of-Pocket (per family) $14,450 /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 POS
Includes Child Dental? Yes
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit 20.00% Coinsurance after deductible
Specialist Visit 20.00% Coinsurance after deductible
Emergency Room 20.00% Coinsurance after deductible
Inpatient Facility 20.00% Coinsurance after deductible
Inpatient Physician 20.00% Coinsurance after deductible
Drug Costs
Generic Drugs 20.00% Coinsurance after deductible
Preferred Brand Drugs 25.00% Coinsurance after deductible
Non-preferred Brand Drugs 30.00% Coinsurance after deductible
Specialty Drugs 30.00% 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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