Gold $1,750 – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $30 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,750 per person $1,750 per person |
| Out-of-pocket max | $6,650 per person $13,300 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $300 copay after deductible |
| Ambulance | $30 copay after deductible |
| Hospital stay (facility) | first 5 day(s) $450 then $0 copay after deductible |
| Hospital stay (physician) | $30 copay after deductible |
| Outpatient procedure (facility) | $400 copay after deductible |
| Outpatient procedure (physician) | $400 copay after deductible |
| Physical rehabilitation | $75 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $450 per day after deductible, up to $2,250 copay |
Pharmacy, Drugs, and Medication
| Generic | No charge |
| Brand | $50 per script after deductible copay |
| Non-preferred Brand | $70 per script after deductible copay |
| Specialty | $100 per script after deductible copay |
Lab Tests and Diagnostic Procedures
| X-rays | $65 copay |
| Imaging (CT/PET/MRI) | $250 copay |
| Blood work | $15 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | first 5 day(s) $450 then $0 copay after deductible |
