HMSA Bronze PPO I

18350HI0880033
Expanded Bronze
PPO

HMSA Bronze PPO I is an Expanded Bronze PPO plan by HMSA.

Locations

HMSA Bronze PPO I is offered in the following counties.

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Plan Overview

This is a plan overview for 2025 version of HMSA Bronze PPO I 18350HI0880033.
Insurer: HMSA
Network Type: PPO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 18350HI0880033

Cost-Sharing Overview

HMSA Bronze PPO I offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for HMSA Bronze PPO I?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

HMSA Bronze PPO I offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what HMSA Bronze PPO I covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Covered
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Covered
National Network: Yes

Additional Benefits and Cost-Sharing

HMSA Bronze PPO I includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$50.00 Not ApplicableNot Applicable 70.00% Coinsurance after deductible
Specialist Visit
Covered
$100.00 Not ApplicableNot Applicable 70.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$50.00 Not ApplicableNot Applicable 70.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Hospice Services
Covered
Not Applicable No ChargeNot Applicable 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible Infertility treatment is covered. Refer to the plan brochure for covered services, criteria, and limitations.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Covered
$10.00 Not Applicable$35.00 Not Applicable1.0 Exam(s) per Year Plan will pay up to $35 for out-of-network providers
Urgent Care Centers or Facilities
Covered
$75.00 Not ApplicableNot Applicable 70.00% Coinsurance after deductible
Home Health Care Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible150.0 Visit(s) per Year
Emergency Room Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Bariatric Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible120.0 Days per Year
Prenatal and Postnatal Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$50.00 Not ApplicableNot Applicable 70.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
Covered
$50.00 Not ApplicableNot Applicable 70.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Generic Drugs
Covered
$25.00 Not Applicable$25.00 Copay after deductible 20.00% Coinsurance after deductible
Preferred Brand Drugs
Covered
$50.00 Copay after deductible Not Applicable$50.00 Copay after deductible 20.00% Coinsurance after deductible
Non-Preferred Brand Drugs
Covered
$100.00 Copay after deductible Not Applicable$100.00 Copay after deductible 20.00% Coinsurance after deductible
Specialty Drugs
Covered
$500.00 Copay after deductible Not ApplicableNot Applicable 100.00% Costshare for preferred specialty drugs. ??Refer to plan brochure for non-preferred specialty drug costshare information.
Outpatient Rehabilitation Services
Covered
$50.00 Not ApplicableNot Applicable 70.00% Coinsurance after deductible
Habilitation Services
Covered
$50.00 Not ApplicableNot Applicable 70.00% Coinsurance after deductible Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Chiropractic Care
Not Covered
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Hearing Aids
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible 1 hearing aid per ear every 60 months.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible Precertification is required.
Preventive Care/Screening/Immunization
Covered
Not Applicable 0.00%Not Applicable 70.00% Coinsurance after deductible Quantitative limit units apply, see EHB
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge Not Applicable$35.00 Not Applicable Member owes all charges over $35 when seeing a nonpar provider
Eye Glasses for Children
Covered
No Charge Not Applicable$85.00 Not Applicable Lenses limited to one par per calendar year. Frames limited to one frame every 24 months. Member owes all charges over $85 when seeing a nonpar provider
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$50.00 Not ApplicableNot Applicable 70.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$50.00 Not ApplicableNot Applicable 70.00% Coinsurance after deductible The therapy is short-term, generally not longer than 90 days.
Well Baby Visits and Care
Covered
Not Applicable No ChargeNot Applicable 70.00% Quantitative limit units apply, see EHB
Laboratory Outpatient and Professional Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Transplant
Covered
Not Applicable No ChargeNot Applicable 100.00%
Accidental Dental
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Dialysis
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Allergy Testing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Chemotherapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Radiation
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Diabetes Education
Covered
Not Applicable No ChargeNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Infusion Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
Not Covered
Nutritional Counseling
Covered
No Charge Not ApplicableNot Applicable 70.00% Coinsurance after deductible Counseling for diagnosed eating disorder by a recognized licensed dietician.
Reconstructive Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Gender Affirming Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible Precertification is required
Applied Behavior Analysis Based Therapies
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible Precertification is required
Autism Spectrum Disorders
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Orthodontic Services to Treat Orofacial Anomalies
Covered
Not Applicable 0.00%Not Applicable 0.00% Benefits are limited to a maximum of $6,930 per treatment phase
Telehealth
Covered
$50.00 Not ApplicableNot Applicable 70.00% Coinsurance after deductible

Free Preventive Services

There is no copayment or coinsurance for any of the following HMSA Bronze PPO I preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for HMSA Bronze PPO I including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for HMSA Bronze PPO I?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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