Non-Standard Low Gold: HMO Blue Deductible with Copayment – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $55 copay
Urgent care visit: $55 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | Success
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| Out-of-pocket max | $5,600 per person $11,200 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $55 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $55 copay |
| Emergency room | $350 copay after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | $750 copay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $500 copay after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $55 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $750 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 copay |
| Brand | $50 copay after deductible |
| Non-preferred Brand | $100 copay after deductible |
| Specialty | $100 copay after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $75 copay after deductible |
| Imaging (CT/PET/MRI) | $300 copay after deductible |
| Blood work | $25 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | $750 copay after deductible |
