Blue Value Bronze Complete A | $60 PCP | $20 Tier 1 Rx | Limited Statewide Doctors

Health Insurance Plan Details (2026 Plan)

POS

Bronze

Deductible (per individual)	$4,000 /yr
Deductible (per family)	$8,000 /yr
Max Out-of-Pocket (per individual)	$10,600 /yr
Max Out-of-Pocket (per family)	$21,200 /yr
Plan Type	POS
Includes Child Dental?	Yes
Includes Adult Dental?	No

Medical Services
Preventive Care	No Charge
Primary Care Visit	$60 Copay
Specialist Visit	$120 Copay
Emergency Room	50.00% Coinsurance after deductible
Inpatient Facility	50.00% Coinsurance after deductible
Inpatient Physician	50.00% Coinsurance after deductible

Drug Costs
Generic Drugs	$20 Copay
Preferred Brand Drugs	$75 Copay after deductible
Non-preferred Brand Drugs	$150 Copay after deductible
Specialty Drugs	50.00% Coinsurance after deductible

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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