Individual & Family Plans Plan Details
Essential Bronze HSA 2024
Greater provider selection at a lower cost.
ANNUAL DEDUCTIBLE
$6,400
OUT-OF-POCKET MAX
$7,400
COPAY
Prescription Drug Coverage
Generic Drugs
Coverage
Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
30 Days
per month
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Preferred Brand Drugs
Coverage
Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
30 Days
per month
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Non-Preferred Brand Drugs
Coverage
Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
30 Days
per month
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Specialty Drugs
Coverage
First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill.
30 Days
per month
Coinsurance
50.00% Coinsurance
after deductible
Copay
Not Applicable
Physician Office Services
Primary Care Visit to Treat an Injury or Illness
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Specialist Visit
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Urgent Care and Emergency
Urgent Care Centers or Facilities
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Emergency Room Services
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Hospital and Surgical Care
Inpatient Hospital Services (e.g., Hospital Stay)
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Outpatient Surgery Physician/Surgical Services
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Inpatient Physician and Surgical Services
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Laboratory Outpatient and Professional Services
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Outpatient Diagnostic Services
Laboratory Outpatient and Professional Services
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
X-rays and Diagnostic Imaging
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Imaging (CT/PET Scans, MRIs)
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Other Benefits
Mental/Behavioral Health Outpatient Services
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Substance Abuse Disorder Outpatient Services
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Outpatient Rehabilitation Services
Coverage
25 Visit(s)
per year
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Habilitation Services
Coverage
Coverage for habilitative services is limited to 30-inpatient days/year. Coverage for habilitative services is limited to 25-outpatient visits/year.
30 Visit(s)
per year
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Prenatal and Postnatal Care
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Delivery and All Inpatient Services for Maternity Care
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Vision
Routine Eye Exam (Adult)
Not covered
Routine Eye Exam for Children
Coverage
1 Exam(s)
per year
Coinsurance
40.00%
Copay
Not Applicable
Eye Glasses for Children
Coverage
Coverage is limited to one frame and one pair (two lenses)/ calendar year or contacts (in lieu of glasses).
1 Item(s)
per year
Coinsurance
No Charge
Copay
No Charge
Adult Dental Coverage
Routine Dental Services (Adult)
Not covered
Basic Dental Care - Adult
Not covered
Major Dental Care - Adult
Not covered
Orthodontia - Adult
Not covered
Child Dental Coverage
Dental Check-Up for Children
Not covered
Basic Dental Care - Child
Not covered
Major Dental Care - Child
Not covered
Orthodontia - Child
Not covered
Use our Quick Quote tool to see pricing for your county
Need help with enrollment?
To learn more about the plans we offer, and how to apply, call LifeWise at