Benefit Explanation: Bronze Essential first 4 PCP, Specialists, Urgent care office visits combined per calendar year; are not subject to the deductible for in-network providers. See policy for more information.
Specialist
CoPay: $60.00 Copay with deductible
CoInsurance: 10.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Bronze Essential first 4 PCP, Specialists, Urgent care office visits combined per calendar year; are not subject to the deductible for in-network providers. See policy for more information.
Prescription Drug Information
Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: See policy for more information.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: See policy for more information.
Generic Drugs
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: See policy for more information.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: See policy for more information.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 10.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: See policy for more information.
Inpatient Services
CoPay: Not Applicable
CoInsurance: 10.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: See policy for more information.
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 10.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: See policy for more information.
Urgent Care Facility
CoPay: $60.00 Copay with deductible
CoInsurance: 10.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Bronze Essential first 4 PCP, Specialists, Urgent care office visits combined per calendar year; are not subject to the deductible for in-network providers. See policy for more information.
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 10.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: See policy for more information.
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: 10.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: See policy for more information.
Vision
Routine Eye Exams For Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: See policy for more information.
Major Dental Care
Routine Dental Checkups for Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 2
Limit Unit : Exam(s) per Year
Benefit Explanation: See policy for more information.
Basic Dental Care - Child
CoPay: Not Applicable
CoInsurance: 20.00%
Covered: Covered
Limit Quantity: 2
Limit Unit : Exam(s) per Year
Benefit Explanation: See policy for more information.
Major Dental Care - Child
CoPay: Not Applicable
CoInsurance: 50.00%
Covered: Covered
Benefit Explanation: Quantitative limits apply. See policy for more information.