Bronze 4000 Ded/9450 MOOP

Health Insurance Plan Details (2024 Plan)

by Group Health Cooperative of South Central Wisconsin

Monthly Premium

HMO
$ubsidy
Bronze
Deductible
$4,000 /yr
Max Out-of-Pocket
$9,450 /yr

Details

Deductible (per individual) $4,000 /yr
Deductible (per family) $8,000 /yr
Max Out-of-Pocket (per individual) $9,450 /yr
Max Out-of-Pocket (per family) $18,900 /yr
Drug Deductible (per individual) $0
Drug Deductible (per family) $0
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
Medical Services
Preventive Care No Charge
Primary Care Visit $125 Copay
Specialist Visit $250 Copay
Emergency Room 40% Coinsurance after deductible
Inpatient Facility 40% Coinsurance after deductible
Inpatient Physician 40% Coinsurance after deductible
Drug Costs
Generic Drugs $50 Copay
Preferred Brand Drugs $200 Copay
Non-preferred Brand Drugs $300 Copay
Specialty Drugs 50% Coinsurance

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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