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Plan Type HMO
Metal Level Bronze
Office Visit for Primary Doctor
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$35 Copay for first 3 visits, then 40% Coinsurance after deductible
Office Visit for Specialist 40% Coinsurance after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) $35 Copay for first 3 visits, then 40% Coinsurance after deductible
Annual Deductible Individual: $4,000
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 40%
Retail Prescription Drugs Generic Drugs: 40% Coinsurance after deductible
Preferred Brand Drugs: 40% Coinsurance after deductible
Non-Preferred Brand Drugs: 40% Coinsurance after deductible
Specialty Drugs: 40% Coinsurance after deductible
Annual Out-of-Pocket Limit Individual: $6,350
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Emergency Care Only 
Out-of-Country Coverage Yes. Emergency and Urgent Care only. 
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required Yes
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 $200 Copay (waived if admitted ) then 40% Coinsurance after deductible
Emergency Ambulance Services 40% Coinsurance after deductible
Urgent Care Facility $50 Copay then 40% Coinsurance after deductible
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: 40% Coinsurance after deductible
Preferred Brand Drugs: 40% Coinsurance after deductible
Non-Preferred Brand Drugs: 40% Coinsurance after deductible
Specialty Drugs: 40% Coinsurance after deductible
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs Generic Drugs: 40% Coinsurance after deductible
Preferred Brand Drugs: 40% Coinsurance after deductible
Non-Preferred Brand Drugs: 40% Coinsurance after deductible
Specialty Drugs: 40% Coinsurance after deductible
Mail Order Supply 90, except specialty which will be 30
Outpatient Coverage
Outpatient Surgery 40% Coinsurance after deductible
Outpatient Lab/X-Ray 40% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) 40% Coinsurance after deductible
Outpatient Mental Health 40% Coinsurance after deductible
Outpatient Substance Abuse 40% Coinsurance after deductible
Outpatient Rehabilitation Services (PT, OT, ST) 40% Coinsurance after deductible, 60 Visit(s) per Lifetime
Inpatient Coverage
Hospitalization $1000 Copay per Stay, then 40% Coinsurance after deductible
Skilled Nursing Facility 40% Coinsurance after deductible, 200 Days per year
Inpatient Mental Health $1000 Copay then 40% Coinsurance after deductible
Inpatient Substance Abuse $1000 Copay before deductible, 40% Coinsurance after deductible
Home Healthcare 40% Coinsurance after deductible, 40 Visit(s) per year
Maternity Coverage
Pre & Postnatal Office Visit 40% Coinsurance after deductible
Labor & Delivery Hospital Stay $1000 Copay then 40% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children $0 Copay, 1 Exam(s) per Year
Eye Glasses for Children $0 Copay, 1 Item(s) per year
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage 40% Coinsurance after deductible
Durable Medical Equipment 40% Coinsurance after deductible
Hospice 40% Coinsurance after deductible, 210 Days per Year
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 06/06/2014
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Summary of Benefits & Coverage (Not available)

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.

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Important notices and disclaimers

  • The benefits matrix is a summary for informational purposes only. Review the evidence of coverage and insurance policy (plan contract) 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.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • 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.