Principal Bronze HSA

Ambetter Health of Delaware

Expanded BronzeHSA eligible

Ind. deductible: $5,200
Family deductible: $5,200
Ind. OOP max: $8,050
Family OOP max: $8,050

Other cost-sharing reduction variants for this plan:

Limited Cost Sharing Plan Variation Standard Bronze Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$465	—
30	$528	—
40	$595	—
50	$831	—
60	$1,263	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	No charge
Primary Care Visit to Treat an Injury or Illness	$60.00 Copay after deductible

Specialist

Benefit	In-network
Specialist Visit	$100.00 Copay after deductible

Hospital

Benefit	In-network
Emergency Room Services	50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	50.00% Coinsurance after deductible
Mental/Behavioral Health Emergency Room	50.00% Coinsurance after deductible
Mental/Behavioral Health Urgent Care	$60.00 Copay after deductible
Outpatient Surgery Physician/Surgical Services	$0.00
Substance Use Disorder Emergency Room	50.00% Coinsurance after deductible
Substance Use Disorder Urgent Care	$60.00 Copay after deductible
Urgent Care Centers or Facilities	$60.00 Copay after deductible

Pharmacy

Benefit	In-network
Generic Drugs	$0.00
Non-Preferred Brand Drugs	45.00% Coinsurance after deductible
Preferred Brand Drugs	$150.00 Copay after deductible
Specialty Drugs	50.00% Coinsurance after deductible
Tier 1b Generic Drugs	$0.00

Mental Health

Benefit	In-network
Mental/Behavioral Health Emergency Transportation/Ambulance	50.00% Coinsurance after deductible
Mental/Behavioral Health ER Physician Fee	50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services	50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Other Services	50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	$60.00 Copay after deductible
Substance Use Disorder Emergency Transportation/Ambulance	50.00% Coinsurance after deductible
Substance Use Disorder ER Physician Fee	$0.00
Substance Use Disorder Outpatient Other Services	50.00% Coinsurance after deductible

Other

Benefit	In-network
Abortion for Which Public Funding is Prohibited	No Charge after deductible
Accidental Dental	50.00% Coinsurance after deductible
Acupuncture	Not covered
Allergy Testing	$100.00 Copay after deductible
Bariatric Surgery	50.00% Coinsurance after deductible
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	Not covered
Chemotherapy	$0.00
Chiropractic Care	$100.00 Copay after deductible
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	$0.00
Dental Check-Up for Children	Not covered
Diabetes Education	$100.00 Copay after deductible
Dialysis	50.00% Coinsurance after deductible
Durable Medical Equipment	50.00% Coinsurance after deductible
Emergency Transportation/Ambulance	50.00% Coinsurance after deductible
Eye Glasses for Children	No charge
Habilitation Services	$100.00 Copay after deductible
Hearing Aids	50.00% Coinsurance after deductible
Home Health Care Services	$0.00
Hospice Services	50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)	50.00% Coinsurance after deductible
Infertility Treatment	50.00% Coinsurance after deductible
Infusion Therapy	50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	$60.00 Copay after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	Not covered
Nutritional Counseling	$100.00 Copay after deductible
Orthodontia - Adult	Not covered
Orthodontia - Child	Not covered
Other Practitioner Office Visit (Nurse, Physician Assistant)	$60.00 Copay after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	50.00% Coinsurance after deductible
Outpatient Rehabilitation Services	$100.00 Copay after deductible
Prenatal and Postnatal Care	$0.00
Private-Duty Nursing	$0.00
Prosthetic Devices	50.00% Coinsurance after deductible
Radiation	50.00% Coinsurance after deductible
Reconstructive Surgery	50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	$0.00
Rehabilitative Speech Therapy	$100.00 Copay after deductible
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	$0.00
Routine Foot Care	$100.00 Copay after deductible
Skilled Nursing Facility	$0.00
Substance Abuse Disorder Inpatient Services	50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	$60.00 Copay after deductible
Transplant	50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders	50.00% Coinsurance after deductible
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	50.00% Coinsurance after deductible

Plan rules

Service area

This plan covers 1 geographic area.