Market HMO 5250 HSA – Mercy

Plan Type: HMO
Plan Tier: Bronze
Medical Deductible - Individual: $5,250
Medical Deductible - Family: $10,500
Drug Deductible - Individual: Included in Medical
Drug Deductible - Family: Included in Medical
Out of Pocket Max - Individual: $6,650
Out of Pocket Max - Family: $13,300
Primary Care Visit: No Charge after Deductible
Specialist Visit: No Charge after Deductible
Emergency Room: No Charge after Deductible
Hospital - Physician: No Charge after Deductible
Hospital - Facility: No Charge after Deductible
Link to Full SBC: https://mybrokerlink.com/GetSbc?mmi=005006016000000000
Plan Brochure:

Other Coverage:

Child Dental: No
Adult Dental No

Prescription Drug Pricing:

Generic Drugs: $40 Copay after deductible
Non-Preferred Brand Drugs: 50% Coinsurance after deductible
Preferred Brand Drugs: $80 Copay after deductible
Specialty Drugs: 50% Coinsurance after deductible
Link to Full Policy Formulary: https://www.medmutual.com/~/media/46857AF483D94EA49ADA66A2EAE7A784.ashx

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