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Market HMO 5250 HSA – ProMedica
| 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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