Bronze 60 HDHP (HSA Compatible)

The amounts (co-pays) listed in the chart below are what you are responsible to pay when using in-network Doctors and Hospitals.
Key benefits Bronze 60 HDHP (HSA Compatible)
Benefits in Orange are Subject to Deductibles
Individual Deductible $4,800 integrated medical and pharmacy deductible
Family Deductible $9,600 integrated medical and pharmacy deductible
Preventative Care no cost1
Primary Care Visit Copay 40%
Urgent Care Visit Copay 40%
Specialty Care Visit Copay 40%
Mental Health & Substance Abuse Outpatient Office Visits 40%
Lab Testing Copay 40%
X-Ray Copay 40%
Imaging Copay 40%
Outpatient services 40%
Emergency Room Copay 40%
Emergency Room Transportation Copay 40%
High cost and inpatient services (e.g. Hospital stay) 40%
Inpatient Hospital Physician services 40%
Tier 1 - Most Generic Drugs 40% up to $500 maximum per prescription
Tier 2 - Preferred Brand Drugs 40% up to $500 maximum per prescription
Tier 3 - Non-Preferred Brand Drugs 40% up to $500 maximum per prescription
Tier 4 - Specialty Drugs 40% up to $500 maximum per prescription
Maximum Out-Of-Pocket For One $6,550
Maximum Out-Of-Pocket For Family $13,100
1 in-network only
2 Copay is limited to the first three visits in total. That includes any combination of Primary Care, Specialist, Mental Health, or Urgent Care visits. After three visits, future visits will be at full cost until the out-of-pocket maximum is met.
3 See the plan's Summary of Benefits to determine if $ or % is due.
Key benefits Bronze 60 HDHP (HSA Compatible)