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Group Bronze HMO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-855-475-3702.

Important Questions
Why this Matters:
What is the overall deductible?
For participating providers
$4,750 person/$9,500 family

Physician office visit, urgent care visit, and prescription drug
copayments and coinsurances are not subject to the
You must pay all the costs up to the deductible amount before this plan begins to pay for
covered services you use. Check your policy or plan document to see when the deductible
starts over (usually, but not always, January 1st). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.
Are there other deductibles for specific services?
You don't have to meet deductibles for specific services, but see the chart starting on page
2 for other costs for services this plan covers.
Is there an out–of–pocket limit on my expenses?
Yes. For participating providers
$6,350 person/ $12,700 family

The out-of-pocket limit is the most you could pay during a coverage period (usually one
year) for your share of the cost of covered services. This limit helps you plan for health
care expenses.

What is not included in the out–of–pocket limit?
Premiums, balance-billed charges, and health care this plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall annual limit on what the plan pays?
The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
Does this plan use a network of providers?
Yes. Call 1-855-475-3702 for a list of
participating providers.
If you use an in-network doctor or other health care provider, this plan will pay some or all
of the costs of covered services. Be aware, your in-network doctor or hospital may use an
out-of-network provider for some services. Plans use the term in-network, preferred, or
participating for providers in their network. See the chart starting on page 2.

Download the Plan Summary of Benefits and Coverage for More Details.


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