Connect Bronze 0 Indiv Med Deductible
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Plan Summary | |
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Plan Type | HMO |
Metal Level | Bronze |
Office Visit for Primary Doctor
Find Doctors |
$55 Copay |
Office Visit for Specialist | $125 Copay |
Office Visit for Other Practitioner (Nurse, Physician Assistant) | $125 Copay |
Annual Deductible | None |
Separate Prescription Drugs Deductible | $5500 per person | $11000 per group |
Coinsurance | 50% |
Retail Prescription Drugs | Generic Drugs: $5 Copay; Preferred Brand Drugs: $250 Copay; Non-Preferred Brand Drugs: 49% Coinsurance after deductible; Specialty Drugs: 50% Coinsurance after deductible; |
Annual Out-of-Pocket Limit | Individual: $9,200 |
Lifetime Maximum | Unlimited |
Health Savings Account (HSA) Eligible | No |
Out-of-Network Coverage | Emergency Care Only |
Out-of-Country Coverage | Yes. Emergency Only |
Office Visit | |
Primary Care Physician Required | Yes |
Specialist Referrals Required | No |
Preventive Care Coverage | |
Periodic Health Exam | No Charge |
Periodic OB-GYN Exam | No Charge |
Well Baby Care | No Charge |
Emergency and Urgent Care | |
Emergency Room | $1,800 Copay |
Emergency Ambulance Services | 50% Coinsurance |
Urgent Care Facility | $75 Copay |
Prescription Drug Coverage | |
Retail Prescription Drugs | Generic Drugs: $5 Copay; Preferred Brand Drugs: $250 Copay; Non-Preferred Brand Drugs: 49% Coinsurance after deductible; Specialty Drugs: 50% Coinsurance after deductible; |
Separate Prescription Drugs Deductible | $5500 per person | $11000 per group |
Mail Order Prescription Drugs | N/A |
Mail Order Supply | N/A |
Outpatient Coverage | |
Outpatient Surgery | Outpatient Surgery Physician/Surgical Services: 50% Coinsurance Outpatient Facility Fee: 50% Coinsurance |
Outpatient Lab/X-Ray | Outpatient Lab: $70 Copay X-rays: 50% Coinsurance |
Imaging (CT and PET scans, MRIs) | 50% Coinsurance |
Outpatient Mental Health | $125 Copay |
Outpatient Substance Abuse | $125 Copay |
Outpatient Rehabilitation Services (PT, OT, ST) | 50% Coinsurance, limited to 40 Visit(s) per Year |
Inpatient Coverage | |
Hospitalization | Inpatient Hospital Services: $2350 Copay per Day, A copay is required for up to 4 days Inpatient Physician and Surgical Services: 50% Coinsurance |
Skilled Nursing Facility | 50% Coinsurance, limited to 60 Days per Year |
Inpatient Mental Health | $2350 Copay per Day, A copay is required for up to 4 days |
Inpatient Substance Abuse | $2350 Copay per Day, A copay is required for up to 4 days |
Home Healthcare | 50% Coinsurance, limited to 120 Visit(s) per Year |
Maternity Coverage | |
Pre & Postnatal Office Visit | 50% Coinsurance |
Labor & Delivery Hospital Stay | $2350 Copay per day, A copay is required for up to 4 days |
Pediatric Services | |
Dental Checkup for Children | Not Covered |
Vision Screening for Children | No Charge, limited to 1 Exam(s) per Year |
Eye Glasses for Children | No Charge, limited to 1 Item(s) per Year |
Major Dental Coverage (Pediatric) | Not Covered |
Additional Coverage | |
Chiropractic Coverage | 50% Coinsurance, limited to 40 Visit(s) per Year |
Durable Medical Equipment | 50% Coinsurance |
Hospice | 50% Coinsurance |
Major Dental Coverage (Adult) | Not Covered |
Vision Coverage (Adult) | Not Covered |
Out-of-Network Coverage | |
Out-of-Network Authorization Required | N/A |
Out-of-Network Annual Deductible | N/A |
Out-of-Network Annual Coinsurance | N/A |
Out-of-Network Annual Out-of-Pocket Limit | N/A |
Additional Information | |
A.M. Best Rating | A as of 04/25/2024 |
Electronic Signature for Application Available | Yes |
Details and documents about this plan | |
View Plan Brochure (Not available)
The carrier has not provided a separate document for Exclusions and Limitations. |
Important notices and disclaimers
- The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
- The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
- The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
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- The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.