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myBlue Bronze 2129V ($0 Virtual PCP Visits / $35 PCP Visits / $75 Specialist Visits / Adult Vision / Rewards)
Health Insurance Plan Details (2025 Plan)
by Health Options, Inc.
Monthly Premium
HMO
$ubsidy
Bronze
- Deductible
- $0 /yr
- Max Out-of-Pocket
- $9,200 /yr
Details
| Deductible (per individual) | $0 /yr |
| Deductible (per family) | $0 /yr |
| Max Out-of-Pocket (per individual) | $9,200 /yr |
| Max Out-of-Pocket (per family) | $18,400 /yr |
| Drug Deductible (per individual) | $2,100 |
| Drug Deductible (per family) | See Plan Brochure |
| Drug Max Out-of-Pocket (per individual) | Included in Medical |
| Drug Max Out-of-Pocket (per family) | Included in Medical |
| Plan Type | HMO |
| Includes Child Dental? | No |
| Includes Adult Dental? | No |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | No Charge |
| Specialist Visit | $20 Copay |
| Emergency Room | $1,125 Copay |
| Inpatient Facility | $3,000 Copay per Day |
| Inpatient Physician | $300 Copay |
| Generic Drugs | $30 Copay |
| Preferred Brand Drugs | $300 Copay |
| Non-preferred Brand Drugs | 50% Coinsurance after deductible |
| Specialty Drugs | 50% Coinsurance after deductible |
Plan Documents
| Summary of Benefits and Coverage | SBC doc |
| Provider Directory | Doctor lookup |
| Drug Formulary List | drug list |
* 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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