Elite Bronze + Vision + Adult Dental

Health Insurance Plan Details (2024 Plan)

Monthly Premium

PPO
$ubsidy
Bronze
Deductible
$0 /yr
Max Out-of-Pocket
$9,250 /yr

Details

Deductible (per individual) $0 /yr
Deductible (per family) $0 /yr
Max Out-of-Pocket (per individual) $9,250 /yr
Max Out-of-Pocket (per family) $18,500 /yr
Drug Deductible (per individual) $3,800
Drug Deductible (per family) $7,600
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type PPO
Includes Child Dental? No
Includes Adult Dental? Yes
Medical Services
Preventive Care No Charge
Primary Care Visit $45 Copay
Specialist Visit $115 Copay
Emergency Room $2,500 Copay
Inpatient Facility $3,000 Copay per Day
Inpatient Physician No Charge
Drug Costs
Generic Drugs $3 Copay
Preferred Brand Drugs $195 Copay
Non-preferred Brand Drugs $250 Copay 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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