Connect Bronze 2250 Indiv Med Deductible
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| Plan Summary | |
|---|---|
| Plan Type | HMO | 
| Metal Level | Bronze | 
| Office Visit for Primary Doctor Find Doctors | $45 Copay | 
| Office Visit for Specialist | $115 Copay | 
| Office Visit for Other Practitioner (Nurse, Physician Assistant) | $115 Copay | 
| Annual Deductible | Individual: $2,250 | 
| Separate Prescription Drugs Deductible | $5250 per person | $10500 per group | 
| Coinsurance | 50% | 
| Retail Prescription Drugs | Generic Drugs: $3 Copay; Preferred Brand Drugs: $200 Copay; Non-Preferred Brand Drugs: 49% Coinsurance after deductible; Specialty Drugs: 50% Coinsurance after deductible; | 
| Annual Out-of-Pocket Limit | Individual: $10,150 Includes deductible | 
| Lifetime Maximum | Unlimited | 
| Health Savings Account (HSA) Eligible | No | 
| Out-of-Network Coverage | Emergency Care Only | 
| Out-of-Country Coverage | Yes. Yes-Emergency 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 | $2,000 Copay | 
| Emergency Ambulance Services | 50% Coinsurance after deductible | 
| Urgent Care Facility | $70 Copay | 
| Prescription Drug Coverage | |
| Retail Prescription Drugs | Generic Drugs: $3 Copay; Preferred Brand Drugs: $200 Copay; Non-Preferred Brand Drugs: 49% Coinsurance after deductible; Specialty Drugs: 50% Coinsurance after deductible; | 
| Separate Prescription Drugs Deductible | $5250 per person | $10500 per group | 
| Mail Order Prescription Drugs | N/A | 
| Mail Order Supply | N/A | 
| Outpatient Coverage | |
| Outpatient Surgery | Outpatient Surgery Physician/Surgical Services: 50% Coinsurance after deductible Outpatient Facility Fee: 50% Coinsurance after deductible | 
| Outpatient Lab/X-Ray | Outpatient Lab: $75 Copay X-rays: 50% Coinsurance after deductible | 
| Imaging (CT and PET scans, MRIs) | 50% Coinsurance after deductible | 
| Outpatient Mental Health | $45 Copay | 
| Outpatient Substance Abuse | $45 Copay | 
| Outpatient Rehabilitation Services (PT, OT, ST) | 50% Coinsurance after deductible | 
| Inpatient Coverage | |
| Hospitalization | Inpatient Hospital Services: $2500 Copay per Day, A copay is required for up to 3 days Inpatient Physician and Surgical Services: 50% Coinsurance after deductible | 
| Skilled Nursing Facility | 50% Coinsurance after deductible | 
| Inpatient Mental Health | $2500 Copay per Day, A copay is required for up to 3 days | 
| Inpatient Substance Abuse | $2500 Copay per Day, A copay is required for up to 3 days | 
| Home Healthcare | 50% Coinsurance after deductible | 
| Maternity Coverage | |
| Pre & Postnatal Office Visit | 50% Coinsurance after deductible | 
| Labor & Delivery Hospital Stay | $2500 Copay per day, A copay is required for up to 3 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 after deductible, limited to 25 Visit(s) per Year | 
| Durable Medical Equipment | 50% Coinsurance after deductible | 
| Hospice | 50% Coinsurance after deductible | 
| 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 04/08/2025 | 
| Electronic Signature for Application Available | Yes | 
| Details and documents about this plan | |
| View Plan Brochure 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.
- 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.
 



